Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on May 15, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that because of Covid-19 you were 
not able to have someone come and provide the transport. You say that you were forced to use the ambulance. 
The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $225 
copayment for ambulance services/ground trip.  
 
You have been asked to pay $221.22 which is less than your copayment amount of $225 for an ambulance trip. 
Since an ambulance trip was provided, the correct copayment has been applied. Please contact the Plan about 
what copayments may/may not be waived. An ambulance trip falls within the ambulance services/ground trip 
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 an ambulance trip provided by a 
participating provider on May 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and the abutment 
supported crown (D6058) provided on July 1, 2020. 
 
You asked the Plan to pay for the dental services. You say that the member needed these services to restore the 
full crown and implant. The Plan denied your request. The Plan says custom fabricated abutment is not listed as 
a covered service. The Plan says abutment supported crown is not listed as a covered service either. The Plan 
also says that 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. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment 
(D6057) and the abutment supported crown (D6058) provided on July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 10, 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 provider in this case is not a network provider 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 the enrollee by an out-of-network provider 
on July 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88346, 88350) provided on May 6, 
2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (88346, 88350) provided 
on May 6, 2020, by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay the balance bill for ambulance transportation provided on March 
12, 2020. 
 
You asked the Plan to pay the balance bill for ambulance transport. You say that you cannot afford any amount 
more than the copayment which you already paid. The Plan denied your request. The Plan says the copayment 
amount you are being charged is correct, and the Plan does not have the capacity to prevent balance billing 
from this non-contracted provider.  

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 $265 
copayment per date of service, regardless of the number of trips, for ground ambulance service. The rules also 
say that for an out-of-network, Medicare participating provider, neither the Plan nor the enrollee must pay 
balance billing. 
 
You have been asked to pay $265 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance Services 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. The Plan has paid the Medicare allowable amount for these services less the $265 copayment that 
you have been assessed. Therefore, we decided that the Plan does not have to pay the balance bill for 
ambulance transportation provided on March 12, 2020.  
 
Please contact the billing provider regarding any amounts beyond the applicable cost-sharing that you are being 
charged.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for an x-ray (70145) provided on July 14, 2020. 
 
You asked the Plan to pay for an x-ray. You say that the provider performed this service. The Plan denied your 
request. The Plan says that this is a column two code to 32555, which was billed on a separate claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. While 70145 is a column two code to 32555, the Plan has not submitted the 
claim on which 32555 was billed. No documentation of this code being billed was included in the case file; 
therefore, the denial is not substantiated. Therefore, we decided that the Plan has to pay for an x-ray (70145) 
provided on July 14, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on June 11, 2020. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you were not told there would be 
a copayment until the day of the surgery. The Plan denied your request. The Plan says the correct copayment 
has been applied. 
 
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 $225 
copayment for outpatient surgery.  
 
You have been asked to pay a $225 copayment for cataract surgery. Cataract surgery falls within the outpatient 
surgery 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 an outpatient surgery 
provided by a participating provider on June 11, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The 
enrollee's care needs at this point, as a practical matter, can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for transitional care management services (99496) provided 
January 17, 2020. 
 
You asked the Plan to pay for the transitional care management services. You say that place of service 31: 
skilled nursing facility is an acceptable place of service for transitional care management. Please reprocess 
claim for payment. The Plan denied your request. The Plan says incorrect place of service billed as CPT code 
99496 was not the most appropriate services performed for place of service 31. 
 
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 99496 is transitional Care Management Services with the 
following required elements: Communication (direct contact, telephone, electronic) with the patient and/or 
caregiver within 2 business days of discharge Medical decision making of high complexity during the service 
period Face-to-face visit, within 7calendar days of discharge. 
 
We find that CPT code 99496 is not supported in the medical record. Specifically, POS 31 is an inpatient 
facility setting code and, therefore, is not appropriate with TCM codes 99495-99496. Since the patient is 
discharged from the inpatient facility setting and transitioning to the community, the subsequent services would 
be rendered in the patient's community (eg, home, clinic, outpatient facility) and not in the inpatient facility. 
Based on this information, we decided that Medicare rules for coverage of the transitional care management 
services have not been met. Therefore, we decided that the Plan does not have to pay for transitional care 
management services (99496) provided January 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray provided on June 17, 2020. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on the date 
of service. The Plan denied your request. The Plan says an appropriate modifier indicating the service was 
separate/distinct was not appended. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service at issue was billed with a valid modifier to show the 
service was a distinct procedural service. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray 
provided on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99213) 
provided on October 23, 2018, to June 20, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. You say that you have 
never been required to obtain referrals for outpatient mental health. The Plan denied your request. The Plan 
says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly 
denied. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the established patient office or other outpatient 
visit (99213) provided on October 23, 2018, to June 20, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a PSA test (G0103) performed on March 
10, 2020. 
 
You asked the Plan to waive the copayment for a PSA test. You say that this service should be fully covered 
because of the misinformation you received before the test was taken. The Plan denied your request. The Plan 
says the correct copayment was applied. 
 
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 Medicare-covered surgery. The contract also says that for men age 50 and older there is no 
coinsurance, copayment, or deductible for an annual PSA test. 
 
According to Medicare records you were age 49 when a PSA test was performed on March 10, 2020. You have 
been asked to pay $48.72 for a PSA test. A PSA test falls within the "Outpatient Surgery and Other Medical 
Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. This 
means that you have been asked to pay less than the full 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 a PSA test (G0103) performed on March 10, 2020.  
 
Your complaint about receiving erroneous or misleading information about cost-sharing from representatives 
of the Plan 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for procedure on anus and rectum (00902) 
provided on February 27, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the anesthesia for procedure on anus and rectum. You say that you would like 
this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior 
authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the anesthesia for procedure on anus and rectum 
(00902) provided on February 27, 2020, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on July 2, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that your dentist is in-
network, and you have $1,000 of comprehensive coverage. The Plan denied your request. The Plan says this 
service exceeds the frequency limitation in your benefit 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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on May 18, 2020, and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on July 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery provided on February 19, 
2020 and March 18, 2020. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you were not informed the 
provider was not in-network. You say that upon arrival you were asked to pay $350 and you assumed that was 
your copayment. The Plan denied your request. The Plan says the claim for February 19, 2020 reprocessed to 
apply the $350 copayment and the $350 copayment for March 18, 2020 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 $350 
copayment for each Medicare-covered outpatient surgery at an in-network ambulatory surgical center. 
 
You have been asked to pay a $350 copayment for each cataract surgery. The total amount you owe is $700 
($350/surgery x 2 surgeries = $700). Cataract surgery falls within the "Outpatient surgery, including services 
provided at hospital outpatient facilities and ambulatory surgical centers" 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 cataract surgery provided on February 19, 2020 and March 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture (D5213) provided on July 7, 
2020. 
 
You asked the Plan to pay for the maxillary partial denture. You say that your husband and you have the same 
insurance. You also say that your husband's claims get paid, but yours do not. You also say that you are on a 
fixed income. The Plan denied your request. The Plan says this service is not a covered benefit under your 
dental 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 
maxillary partial denture (D5213) provided on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for echo guidance for a biopsy (76942) and a 
renal biopsy (50200) performed on June 16, 2020. 
 
You asked the Plan to waive the coinsurance for echo guidance for a biopsy and a renal biopsy. You say that 
you were unaware this would be billed as out-of-network services. The Plan denied your request. The Plan says 
the correct coinsurance was applied. 
 
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 30% 
coinsurance for out-of-network physician/practitioner services.  
 
You have been asked to pay $48.24, or 30% coinsurance of the Plan-allowed amount of $160.81, for echo 
guidance for a biopsy and a renal biopsy performed by an out-of-network provider. Echo guidance for a biopsy 
and a renal biopsy fall within the "Physician/Practitioner services, including doctor's office visits" 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 coinsurance for echo guidance for a biopsy (76942) and a 
renal biopsy (50200) performed on June 16, 2020.