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

 
We decided that the Plan does not have to waive the copayment for an office visit provided by a participating 
provider on December 20, 2019. 
 
You asked the Plan to waive the copayment for an office visit. You say that you went for your physical. 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 $20 
copayment for physician/practitioner services/primary care doctor.  
 
You have been asked to pay $19.99 which is less than your copayment amount of $20 for an office visit. When 
services are provided that go beyond an annual wellness exam, additional copayments can be applied; 
therefore, the correct copayment has been applied. An office visit falls within the physician/practitioner 
services/primary care doctor 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 office 
visit provided by a participating provider on December 20, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (EKG) interpretation(93010) provided 
April 16, 2020. 
 
You asked the Plan to pay for the EKG reading. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documents do not support the CPT code billed. 
 
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 code 93010 is not supported in the medical record. Specifically, the documentation only 
included an EKG strip. There was no interpretive report. Without a full interpretive report, a professional 
component billing is not supported. Reimbursement for a simple EKG reading is included in the Emergency 
Room evaluation payment. Based on this information, we decided that Medicare rules for coverage of the EKG 
reading have not been met. Therefore, we decided that the Plan does not have to pay for an electrocardiogram 
(EKG) interpretation(93010) provided April 16, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to waive the additional copayment applied to the application of a multi- layer 
compression system to the leg during an occupational therapy visit provided on January 13, 2020 billed with 
code 29581-GO. 
 
You asked the Plan to waive the additional copayment applied to the compression system application.. You say 
that it is felt that an additional copayment is not appropriate as this compression wrapping is a part of the 
occupational therapy plan of care and is billed as such. The Plan denied your request. The Plan says that a 
specialist service copayment was correctly applied to code 29581. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan says that enrollees must pay a 
$25 copayment for Medicare-covered occupational therapy visits. 
 
The Plan says the enrollee must pay an additional $30 copayment for specialist services provided on this date 
of service. However, based on the contract, the enrollee cannot be asked to pay more than a $25 copayment for 
a single occupational therapy visit. The code 29581 was billed with a GO modifier indicating it was performed 
as part of the occupational therapy plan of care. There is no language in the contract which would create a 
reasonable expectation that an additional copayment would be applied to a service provided during an 
occupational therapy visit. There is likewise no evidence to support applying a specialist copayment to this 
service as it appears this care would have been rendered by the same provider who performed the manual 
therapy. Therefore, we decided that the Plan has to waive the additional copayment applied to the application 
of a multi- layer compression system to the leg during an occupational therapy visit provided on January 13, 
2020 billed with code 29581-GO.  
 
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 unspecified preventive procedure (D1999) provided on 
May 21, 2020. 
 
You asked the Plan to pay for the unspecified preventive procedure (D1999). You say that the dentist needs to 
salvage the tooth before it cracks more. You say that this is an expensive treatment that you can't afford.  The 
Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
unspecified preventive procedure (D1999) provided on May 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic image (D0350) and interim 
partial denture (D5820) provided on April 25, 2020. 
 
You asked the Plan to pay for the 2D oral/facial photographic image and interim partial denture. You say that 
you cannot afford to pay for these services. The Plan denied your request. The Plan says these services are not 
covered benefits 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 Plans 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 2D 
oral/facial photographic image (D0350) and interim partial denture (D5820) provided on April 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omeprazole Cap 20mg. 
 
You asked the Plan to pre-approve Omeprazole Cap 20mg. You say that the medication is necessary. The Plan 
denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate 
pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Omeprazole Cap 20mg.  
 
Benefits for Omeprazole Cap 20mg 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for percutaneous image guided procedures on the 
spine and spinal cord (01936) provided on February 20, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the anesthesia. You say that you have to see this provider every 6 months for 
ablation where they burn the nerves in your back. You must be put to sleep for the procedure. This is from the 
anesthesiologist and was medically necessary. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. The plan says that non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 anesthesia for percutaneous image guided 
procedures on the spine and spinal cord (01936) provided on February 20, 2020 by an out of network (OON) 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on February 13, 2020. 
 
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 
prior authorization was not obtained as required under the plan benefits. 
 
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 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 diagnostic radiology services provided on February 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on May 14, 2020. 
 
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 after careful review it has been determined that this claim was processed correctly. This 
service was previously paid to a provider in the same specialty and within the same group.  Both the providers 
have same specialty. CMS Correct Coding Initiative (CCI) has identified column I procedure codes and their 
associated column II procedure codes based on the principles of correct coding. Services that are considered 
column II procedures to another service are not eligible for reimbursement when billed with the column I 
procedure code. Procedure code 71045 was denied as the column II code to the column I code 71046. Per 
review of medical records, the documents received supports CPT code 71045 being performed as a separate 
and distinct services during a different session by the denied provider but an appropriate modifier has not been 
appended to show that these procedures were distinct and independent to one another on the claim. Therefore, 
Medicare billing criteria are not met.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code and when necessary the appropriate modifier. 
The claim submitted cannot be paid as billed due to a previous claim paid by the Plan. Medicare rules for 
coverage of this service have not been met due to the lack of an appropriate modifier. Therefore, we decided 
that the Plan does not have to pay for physician services provided to the enrollee on May 14, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for equipment and services provided to the enrollee on February 
1, 2020. 
 
You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says the enrollee's primary insurer must be billed first. When the provider 
submits an explanation of benefits from the primary insurer, the Plan can review for any possible coverage as 
the secondary payer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. The Plan has met its obligation with 
regards to coordination of benefits. Specifically, the Plan has explained how the claim should be submitted to 
the primary payer and the process for getting paid after that is done. As the secondary insurer, the Plan cannot 
be held responsible for this claim until the primary insurer has denied the claim for these services.  Therefore, 
we decided that the Plan does not have to pay for equipment and services provided to the enrollee on February 
1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional extraction provided on May 14, 2020. 
 
You asked the Plan to pay for the additional extraction. You say that you were referred by your in-network 
dentist. You say that you had no choice and could no longer wait. The Plan denied your request. The Plan says 
only two extractions are covered per calendar year. 
 
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, you also have a maximum benefit of 
two extractions per calendar year. The Plan paid for two extractions and analgesia provided on May 14, 2020, 
which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the additional 
extraction provided on May 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic visits from March 2, 2020 to March 30, 2020. 
  
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says any services beyond 20 visits are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The Plan contract only covers 20 visits per year. 
Once that benefit is exhausted it is not extended by Medicare or the Plan. Therefore, we decided that the Plan 
does not have to pay for chiropractic visits from March 2, 2020 to March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay $111.17 for physician services provided on March 5, 2020. 
 
You asked the Plan to pay this service. You say that the Plan should pay for this service. The Plan denied your 
request. The Plan says the cost of this service was applied to your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1500 deductible for 2020. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is deductible. This cost sharing is a contractual obligation that had 
not been met at the time this service was received on March 5, 2020. Therefore, we decided that the Plan does 
not have to pay $111.17 for physician services provided on March 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Toric Lenses (66999) provided September 11, 2019 to 
September 25, 2019. 
 
You asked the Plan to pay for the lenses. You say that you cannot wear glasses because they cause difficulties 
seeing at night, and therefore these lenses were medically necessary. The Plan denied your request. The Plan 
says this type of lens is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for Toric Lenses (66999) 
provided September 11, 2019 to September 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required, 
gingivectomy or gingivoplasty, crown, and two drugs or medicaments dispensed in the office for home use  
provided on May 6, 2020. 
 
You asked the Plan to pay for the core buildup, gingivectomy or gingivoplasty, crown, and drugs or 
medicaments. You say that you only agreed to pay the amount of $1,545.50, which was the amount that you 
were told you would pay for these services. 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 Plans 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 core 
buildup, including any pins when required, gingivectomy or gingivoplasty, crown, and two drugs or 
medicaments dispensed in the office for home use  provided on May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the 20% coinsurance charged for outpatient 
radiation therapy provided from April 3, 2020 to April 24, 2020. 
 
You asked the Plan to waive or reduce this coinsurance. You say that you do not believe this coinsurance is 
correct. The Plan denied your request. The Plan says this coinsurance was charged based on the services 
provided and the Plan contract agreement. 
 
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 outpatient radiation therapy provided in an outpatient hospital setting.  
 
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 or reduce the 20% coinsurance charged for outpatient radiation therapy provided from 
April 3, 2020 to April 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $30 copayment for lab services provided on April 17, 
2020. 
 
You asked the Plan to waive this copayment. You say that you had the same services done at the VA and feel 
you should not have to pay for both. The Plan denied your request. The Plan says this copayment was charged 
based on the services provided and the Plan contract agreement. 
 
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 
copayment for outpatient lab services.  
 
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 $30 copayment for lab services provided on April 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that after you were looked at, it was determined 
that you did not need to go to the hospital. 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 September 28, 2019. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on October 22, 
2019. 
 
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 the enrollee did not have prior authorization for out of network care. 
 
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 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 physician services provided to the enrollee on October 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on July 23, 2019. 
 
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 you are not an eligible Medicare provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who is not a Medicare eligible provider.  
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on July 
23, 2019.