Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Neuromuscular stimulator, electronic shock unit provided 
April 9, 2020. 
 
You asked the Plan to pay for the Neuromuscular stimulator. You say that please see attached medical records 
and supporting documents confirming medical necessity. The Plan denied your request. The Plan says there is 
no actual physical exam. All information was provided over the phone. No actual treatment records were 
provided to substantiate the enrollee's orally reported medical history and the enrollee is not in an eligible 
geographical area for telehealth services. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the Neuromuscular 
stimulator, electronic shock unit provided April 9, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan you had on May 12, 2020. 
 
You asked the Plan to waive the copayment for the duplex scan. You say that you just had an ultrasound and 
usually you only pay $10 for these. The Plan denied your request. The Plan says you had a scan in addition to 
the ultrasound, so the copayment 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 $20 
copayment for diagnostic tests with a Specialist.  
 
Records show that you went to the radiologist?s office on May 12, 2020 and were provided two separate 
services: an ultrasound, and a duplex scan. You have been asked to pay a $20 copayment for the duplex scan. 
You Evidence of Coverage says that you pay a $20 copayment for diagnostic tests you receive from a 
specialist.  A duplex scan is a diagnostic test and a radiologist is a specialist. 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 duplex scan you had on May 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray, prophylaxis, and periodic 
oral evaluation provided on March 2, 2020 by an OON provider. 
 
You asked the Plan to pay for the first intraoral periapical x-ray, prophylaxis, and periodic oral evaluation. You 
say that you have never been informed that not all of the dentists at this facility are in-network. The Plan denied 
your request. The Plan says the treating provider does not participate with 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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the first 
intraoral periapical x-ray, prophylaxis, and periodic oral evaluation provided on March 2, 2020 by an OON 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist visits provided on March 9, 
2020 and March 20, 2020. 
 
You asked the Plan to waive the copayments for specialist visits. You say that you disagree with the charges 
because these were follow-up visits. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
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 each specialist visit. 
 
You had a specialist visit on March 9, 2020. Follow-up visits are subject to cost-sharing charges. Therefore, 
you are responsible to pay the $45 copayment.  
 
You had a specialist visit on March 20, 2020. Follow-up visits are subject to cost-sharing charges. Therefore, 
you are responsible to pay $24.10, which is less than the $45 copayment. 
 
The total amount you owe is: $69.10. 
 
You have been asked to pay the total copayment amount of $69.10 for specialist visits. Specialist visits 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 copayments for specialist visits provided on March 9, 2020 and March 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services 
provided on April 14, 2020. 
 
You asked the Plan to pay for the infectious agent detection by nucleic acid services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are 
not a c overed benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
Review of the file shows that the plan uses Local Coverage Article (LCA), A57579 to support their denial. 
However, LCA A57579 is not valid for Part B for the state of New Jersey. Therefore, we cannot use LCA 
A57579 to substantiate our decision. 
 
The  infectious agent detection by nucleic acid testing at issue in this appeal was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the infectious agent detection by nucleic acid services provided on April 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on January 17, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for outpatient 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. 
 
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 outpatient services provided on January 17, 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 pontic (D6245) and two retainer crowns (D6740 x2) 
provided on March 5, 2020. 
 
You asked the Plan to pay for the pontic and retainer crowns. You say that these services were medically 
necessary. You also say that the provider was told these services were covered when he contacted the Plan. The 
Plan denied your request. The Plan says these services 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 pontic 
(D6245) and two retainer crowns (D6740 x2) provided on March 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ultrasound services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the ultrasound services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the ultrasound services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided April 22, 
2020. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that the item was medically necessary. 
The Plan denied your request. The Plan says rules for telehealth consults were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
There was no physical exam or any documentation showing the prescribing provider contacted the enrollee's 
primary physician. This means that the telehealth visit is not a covered service under the Medicare program and 
cannot substitute for an in-person encounter. Consequently, the items/services ordered following the 
noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a 
neuromuscular stimulator (E0745) provided April 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the level 2 molecular pathology procedures provided on 
November 14, 2019. 
 
You asked the Plan to pay for the level 2 molecular pathology procedures. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The level 2 molecular pathology procedures at issue in this appeal were requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the level 2 molecular pathology procedures provided on November 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two extractions, problem focused limited oral evaluation, 
and addition of tooth to an existing partial denture provided on March 11, 2020 by an OON provider. 
 
You asked the Plan to pay for the extractions, problem focused limited oral evaluation, and addition of tooth to 
an existing partial denture. The Plan denied your request. The Plan says the full allowance for the year was paid 
to you on this claim. 
 
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 $250 annual 
allowance for Non-Medicare-covered preventive and comprehensive dental services combined. The contract 
says that after your annual allowance has been met, you are responsible for the full charges of any additional 
dental services. The record shows that you met the annual allowance while processing this claim for the March 
11, 2020 date of service, and your annual allowance has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the two extractions, problem focused limited oral evaluation, and addition of tooth to 
an existing partial denture provided on March 11, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 31, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that the provider should not be penalized for lack of 
authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the facility 
or provider. 
 
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 psychotherapy provided on March 31, 2020 by an 
out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 11, 2019. 
 
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 codes 81401-90, 81227-90, 81225-90, 81226-90, 81479-90, 81230-90, 
81231-90, 81240-90, 81241-90 and 81291-90 are 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. 
 
We find that CPT codes 81401-90, 81227-90, 81225-90, 81226-90, 81479-90, 81230-90, 81231-90, 81240-90, 
81241-90 and 81291-90 are not supported in the medical record. Specifically, there are no records for the billed 
date of service. 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 
July 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 20, 2019 by an 
out of network (OON) provider. 
 
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 services were rendered by an out-of-network provider without prior authorization. 
 
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 medical services provided on September 20, 
2019 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental health services you had 
on February 11, 2020. 
 
You asked the Plan to waive the copayment for the outpatient mental health services. You say that you should 
not be charged more for mental health care than you would be for medical health care. You stated that the 
Mental Health Parity and Addiction Equity Act says that you should only be responsible for the same $0 
copayment you would have for other specialty care. 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 $40 
copayment for Medicare-covered outpatient mental health services.  
 
You have been asked to pay a $40 copayment for the outpatient mental health services. Please note that the 
Mental Health Parity and Addiction Equity Act is not applicable to stand-alone Medicare Advantage Plans such 
as the Plan in this case.  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 outpatient mental health services 
you had on February 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Neuromuscular stimulator, electronic shock unit (E0745) 
provided April 9, 2020. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that please see the attached medical 
records and supporting documents confirming medical necessity. The Plan denied your request. The Plan says 
there is no actual physical exam. All information was provided over the phone. No actual treatment records 
were provided to substantiate the enrollee's orally reported medical history and the enrollee is not in an eligible 
geographical area for telehealth services. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for Neuromuscular stimulator, 
electronic shock unit (E0745) provided April 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI scan of the brain (70553) 
performed on May 24, 2020. 
 
You asked the Plan to waive the copayment for an MRI scan of the brain. 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 $325 
copayment for diagnostic radiology other than CT scans.  
 
You have been asked to pay a $325 copayment for an MRI scan of the brain. An MRI scan of the brain falls 
within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 MRI scan of the brain (70553) performed on May 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on August 27, 2019 to September 19, 
2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that your daughter brought you here because you felt your lab 
tests were abnormal and you wanted them tested again. The Plan denied your request. The Plan says prior 
authorization was not obtained. 
 
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 lab work provided on August 27, 2019 to 
September 19, 2019 by an out of network (OON) provider.