Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient stay provided from April 26, 
2020, through April 29, 2020. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that you weren't given a choice of 
what hospital to go to. You say that you are appealing to pay the claims as in-network instead of out-of-
network. The Plan denied your request. The Plan says 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 $295 
copayment per day, for days 1 to 5 at an in-network inpatient hospital. 
 
You have been asked to pay an $885 copayment for the inpatient stay. ($295/day x 3 days = $885). The 
inpatient stay falls within the "Inpatient hospital care" benefit category. The records show that you were 
charged the in-network rate. 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 inpatient stay provided 
from April 26, 2020, through April 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure, first intraoral periapical x-ray, and 
additional intraoral periapical x-ray provided. 
 
You asked the Plan to pay for the preventive procedure, first intraoral periapical x-ray, and additional intraoral 
periapical x-ray. You say that you were not advised at the provider's office that these services would not be 
covered. 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 
preventive procedure, first intraoral periapical x-ray, and additional intraoral periapical x-ray provided.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for to pay for ambulance transport provided to the enrollee from January 15, 2020, to January 20, 2020.
You asked the Plan to pay for ambulance transport provided to the enrollee January 15, 2020, to January 20, 2020. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim should be submitted to original Medicare.
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 to pay for ambulance transport provided to the enrollee from January 15, 2020, to January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician telephone patient service (99442) provided on 
May 6, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the physician telephone patient service. 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 physician telephone patient service (99442) 
provided on May 6, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for 4 visits for routine chiropractic services
(99203, 97530, 97140) provided on February 12 to March 5, 2020.
You asked the Plan to waive the coinsurance for routine chiropractic services. You say that you should receive
additional reimbursement for these 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 routine chiropractic services.
You have been asked to pay $45.19, or 30% of the Plan-allowed amount of $150.64, for date of service
February 12, 2020. You have also been asked to pay $8.75 per visit, or 30% of the Plan-allowed amount of
$29.18, for 3 additional dates of service (February 20, February 27, and March 5, 2020). 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 4 visits for routine chiropractic services (99203, 97530, 97140)
provided on February 12 to March 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 25, 2020.
You asked the Plan to pay for the ambulance services. You say that this was an emergency and you were
treated in place. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on January 25, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on January 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory service (81001) provided. 
 
You asked the Plan to waive the copayment for laboratory service. You say that the service should be covered. 
The Plan denied your request. The Plan says the cost share is correct 
 
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 $10 
copay for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $10 copay for laboratory service. This service 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 laboratory service (81001) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy (D3310) provided on July 29, 2020. 
 
You asked the Plan to pay for the endodontic therapy. You say that you had a root canal, and the bill was 
$822.00. You also say that you received a 7% discount for a total of $750.00. 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 
endodontic therapy (D3310) provided on July 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four preventive procedures (D1999 x4), add clasp to 
existing partial denture (D5660), and problem focused limited oral evaluation (D0140) provided from June 12, 
2020, to July 8, 2020. 
 
You asked the Plan to pay for the preventive procedures, add clasp to existing partial denture, and problem 
focused limited oral evaluation. You say that you were told that the COVID-19 charge would be covered. The 
Plan denied your request. The Plan says unspecified preventive procedure and add clasp to existing partial 
denture are not covered benefits under your dental plan. The Plan also says that the problem focused limited 
oral evaluation 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, the unspecified preventive procedure 
and add clasp to existing partial denture are not among those covered under this benefit. The contract clearly 
states that 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 June 30, 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 four preventive procedures (D1999 x4), add clasp to existing partial denture 
(D5660), and problem focused limited oral evaluation (D0140) provided from June 12, 2020, to July 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient consultation provided on February 15, 2019 
billed with CPT code 99254. 
 
You asked the Plan to pay for the services as billed. You say that the records support that this claim should be 
paid. The Plan denied your request. The Plan says the code used in this case is not appropriate for Medicare 
billing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 99254 has a status indicator of "I" in the Physician Fee Schedule, which means that it is invalid for 
Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the 
services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient 
consultation provided on February 15, 2019 billed with CPT code 99254.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift. 
 
You asked the Plan to pre-approve a stair lift. You say that the enrollee is unable to climb stairs because of his 
cardiac conditions. The Plan denied your request. The Plan says a stair lift is not for a medical problem. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (CPT 19083) provided to the enrollee on 
September 13, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says modifiers KX should be billed to identify services for transgender, ambiguous genitalia, and 
hermaphrodite beneficiaries. 
 
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 19083 is "Biopsy, breast, with placement of breast 
localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when 
performed, percutaneous, first lesion, including ultrasound guidance." 
 
We find that CPT code 19083 is not supported in the medical record. Specifically, this code needed to be billed 
with the appropriate modifier, as the billed diagnosis code is "malignant neoplasm of unspecified site of left 
female breast)" and the enrollee's gender is male. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for 
radiology services (CPT 19083) provided to the enrollee on September 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) provided on June 5, 2020 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that the services rendered were medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network 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 the office visit (99214) provided on June 5, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 11, 2020 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 August 11, 2020 
by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder x-ray rendered. 
 
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 anatomical modifiers are required for procedures 
performed on different anatomical sites. 
 
We looked at the file and Medicare rules. The file shows that procedure code 73020 was not billed with a 
required anatomical modifier. 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 shoulder x-ray 
rendered.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
August 6, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that every time you go to the dentist, 
they do an evaluation. 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, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on February 3, 2020 and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) provided on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for specialist 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. The 
Plan says that the member's primary care physician did not refer these services. 
 
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 specialist services provided by an 
out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant at surgery services provided on May 28, 2020. 
 
You asked the Plan to pay for assistant at surgery services. You say that this service is payable to an assistant 
surgeon and should be paid at the in-network rate. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because Medicare does not allow assistant at surgery coverage for a 
Registered Nurse First Assistant (RNFA). 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for assistant at surgery services provided 
on May 28, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you would like to 
appeal this copayment. 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 $100 
copayment for emergency care.  
 
You have been asked to pay a $100 copayment for an emergency room visit. An emergency room visit falls 
within the emergency care 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 
emergency room visit provided.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion services rendered from December 18, 
2019 to May 18, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare 
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion services rendered from December 18, 2019 to May 18, 2019.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Magnetic resonance imaging (MRI) scan of leg (73718) provided on July 19, 2020.
You asked the Plan to waive the copayment for the MRI scan of leg. You say that you disagree with the copayment as charged as it seems high. The Plan denied your request. The Plan says the copayment applied correctly in this case.
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 $180 copayment for advanced imaging services. You have been asked to pay a $180 copayment for the MRI scan of leg. the MRI scan of leg falls within the advanced imaging 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. Therefore, we decided that the Plan does not have to waive the copayment for Magnetic resonance imaging (MRI) scan of leg (73718) provided on July 19, 2020.