Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the visit you had with a specialist on 
August 7, 2020 to evaluate your pacemaker. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you have never had to pay a 
copayment for this service in the past.  You also said that you only saw the pacemaker technician.  The Plan 
denied your request. The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for provider and professional services in a specialist's office.  
 
You have been asked to pay a $45 copayment for the specialist visit. This copayment applies even if you see a 
non-physician professional (such as a pacemaker technician) in a specialist's office. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the visit you had with a specialist on August 7, 2020 to evaluate your pacemaker.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
July 4, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you went to the hospital in order to 
get a COVID-19 test.  You said that the ER personnel performed additional services beyond the COVID-19 
test, and you don't think you should have to pay for that. The Plan denied your request. The Plan says you were 
charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for emergency room services.  
 
You have been asked to pay a $120 copayment for the ER visit. This copayment applies regardless of the 
reason for your visit to the ER. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room (ER) 
visit you had on July 4, 2020.  
 
Your complaint about receiving services beyond a COVID-19 test is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Verio Test Strips for the enrollee. 
 
You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied 
your request. The Plan says non-preferred products are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the test strips. Our reviewer says that 
the requested test strips are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no medical reason to choose one test strip over another. The plan provides an adequate 
test strip. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the test strips have not been met. Therefore, we decided that the Plan does not 
have to pre-approve OneTouch Verio Test Strips for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided May 22, 2020, to May 28, 
2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee repeatedly displays poor 
outpatient compliance. You also say that the readmission was medically necessary and warrants payment. The 
Plan denied your request. The Plan says that the enrollee was readmitted to the same hospital within 30 days of 
the index admission. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee has had numerous admissions for small bowel obstructions, each time with the 
same or similar symptoms, and the same pattern of care is implemented. Our reviewer also found that the 
readmission was medically necessary and did not result from a premature discharge from the same hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided May 22, 2020, to May 28, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions provided on June 15, 2020. 
 
You asked the Plan to pay for the extractions. You say that prior to receiving the services, you contacted the 
Plan and were told that they would help cover some of the expenses. You also say that you were not informed 
that there was a benefit maximum. The Plan denied your request. The Plan says as of June 15, 2020, when the 
services were rendered, you had $923 left of the $1000 maximum benefit. The Plan also says that the payment 
was issued to the provider on July 22, 2020 in the amount of $923. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $1,000 benefit 
maximum for preventive and comprehensive dental services. The record shows that you met the annual 
maximum benefit while processing this claim for the services provided on June 15, 2020, and your annual 
maximum benefit has been exhausted. The Plan also confirmed with the provider's office that you were 
informed two times prior to receiving the extractions about your maximum benefit and what was left.  
Therefore, we decided that the Plan does not have to pay for the extractions provided on June 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided . 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was 
enrolled in hospice on the date of service in question. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance services provided.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopy you had at an outpatient 
hospital facility on August 5, 2020. 
 
You asked the Plan to waive the copayment for the endoscopy. You say that this copayment should be waived. 
The Plan denied your request. The Plan says you were charged this copayment correctly.  In addition, the Plan 
states that their COVID-19 copayment waiver program applies only to primary care visits, outpatient 
behavioral health services, and telehealth visits.  It does not apply to surgical services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient surgery in an outpatient hospital facility.  
 
You have been asked to pay a $250 copayment for the endoscopy. The endoscopy falls within the outpatient 
surgery in an outpatient hospital facility benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the endoscopy you had at an outpatient hospital facility on August 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incomplete endodontic therapy (D3332) provided on 
February 27, 2020. 
 
You asked the Plan to pay for the incomplete endodontic therapy. You say that this service should be covered 
because during the root canal it was determined that your tooth needed to be extracted. You also say that the 
Plan covers both extraction and root canal services. The Plan denied your request. The Plan says this service is 
not covered by your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
incomplete endodontic therapy (D3332) provided on February 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services and transcatheter 
stent placement provided on July 23, 2020 and July 31, 2020. 
 
You asked the Plan to waive the copayment for the laboratory services and transcatheter stent placement. You 
say that you shouldn't have to pay for the labs or catheterization because the lab was outside of the hospital. 
You say that you were informed you had a $0 deductible. The Plan denied your request. The Plan says the 
copayments applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for lab services in an outpatient hospital setting and a $90 copayment for diagnostic procedures and 
tests at an outpatient hospital.  
 
You have been asked to pay a total of $104.06 for the laboratory services and transcatheter stent placement.  
 
Date of Service Service Allowed Amount Standard 
Copayment 
Member Liability 
July 23, 2020 Laboratory Services $14.06 $40 $14.06 
July 31, 2020 Transcatheter Stent 
Placement 
$9,724.73 $90 $90 
TOTAL:    $104.06 
 
 
 
 
The laboratory services and transcatheter stent placement fall within the "Outpatient diagnostic tests and 
therapeutic services and supplies" benefit category. The records show the laboratory services and transcatheter 
stent placement were billed by the hospital. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
laboratory services and transcatheter stent placement provided on July 23, 2020 and July 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 4, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 87361 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87361 is infectious agent detection by nucleic acid (DNA 
or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza 
virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and 
multiplex amplified probe technique, multiple types or subtypes, 3-5 targets. 
 
We find that CPT code 87361 is not supported in the medical record. Specifically, there is no documentation of 
a respiratory virus panel. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on May 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on July 15, 2020, and July 21, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network 
services are not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested providers in this case are not network providers with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to you by an out-of-network provider on July 
15, 2020, and July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit rendered on June 15, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the correct POS code.  
 
We looked at the file and Medicare rules. The file shows that procedure code 99337 was billed with POS code 
12 for home. This POS code is not appropriate for the billed services. Therefore, we decided that the Plan does 
not have to pay for the rest home visit rendered on June 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the local anesthesia in conjunction with operative or surgical 
procedure (D9215) provided on July 28, 2020. 
 
You asked the Plan to pay for the dental services. You say that to challenge the provider's treatment choices or 
procedures seems unethical. You say that the provider used what he felt was necessary for your treatment. You 
also say that this puts an extra burden on you while you are working the "front lines" servicing others. The Plan 
denied your request. The Plan says the local anesthesia in conjunction with operative or surgical procedure is 
not listed as a covered service. The Plan also says any services not listed are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the local 
anesthesia in conjunction with operative or surgical procedure (D9215) provided on July 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the back brace you received on June 18, 
2020. 
 
You asked the Plan to waive the coinsurance for the back brace. You say that you were told this item would be 
covered 100%. The Plan denied your request. The Plan says you were charged this coinsurance correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for prosthetic devices and related supplies (including braces).  
 
You have been asked to pay 20% coinsurance for the back brace. The back brace falls within the prosthetic 
devices and related supplies benefit category. The written language in your Evidence of Contract is binding. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the back brace you received on June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out-of-area cataract surgery. 
 
You asked the Plan to pre-approve these services. You say that you are unable to return to the service area. The 
Plan denied your request. The Plan says the services do not meet the out-of-area criteria for coverage. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services do not meet the out-of-area criteria for coverage. Our physician reviewer found the submitted 
records show that you have had a diagnosis of cataracts in both eyes since 2014. There is no documentation to 
support that the requested out-of-area cataract surgery must be performed right away. The surgery can be 
delayed until you return to your service area. The out-of-area services are not reasonable or medically 
necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve out-of-area cataract surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on July 9, 2020
and billed under code 99231.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. The Plan says that per the AMA CPT
Professional Edition Anesthesia Guidelines, "Payment may not be made for services included in the anesthesia
care package when furnished by the same provider or the same provider specialty within a group practice.
Anesthesia care packages consist of pre-op evaluation, standard operation, and monitoring services,
administration of anesthesia and post-op anesthesia recovery care." This service was previously billed by
another provider for the same service, on the same date of service, for the same enrollee.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case, code 99231 cannot be paid as billed due
to previously reported claims. Medicare rules for coverage of this service have not been met. Therefore, we
decided that the Plan does not have to pay for anesthesia services provided to the enrollee on July 9, 2020 and
billed under code 99231.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-rays coded 73600 and 73620 provided on January 31, 
2020. 
 
You asked the Plan to pay for the x-rays. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 73600 and 73620 are not supported in the medical record. Specifically, the submitted 
medical records do not contain sufficient detail to support that radiologic examination, foot, 2 views and 
radiologic examination, ankle, 2 views were performed. Based on this information, we decided that Medicare 
rules for coverage of the x-rays have not been met. Therefore, we decided that the Plan does not have to pay for 
the x-rays coded 73600 and 73620 provided on January 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2 crowns (D2740) and 1 core build up (D2950) provided on 
July 7, 2020. 
 
You asked the Plan to pay for the dental services. You say that the provider was advised by a plan 
representative that the services would be covered. You say that unbeknownst to you, your coverage had 
changed. You say that you were not aware that your coverage was going to expire and not roll over to the next 
year. You also say that you were not advised that you needed to renew the policy before it expired. The Plan 
denied your request. The Plan says the Annual Notice of Change (ANOC) was mailed to you on October 2, 
2019. The Plan says that the ANOC indicates that the optional supplemental dental benefit is not available in 
2020. The Plan also says that crowns and core build up are not listed as covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 2 crowns 
(D2740) and 1 core build up (D2950) provided on July 7, 2020.