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

 
We decided that the Plan does not have to waive the copayment for the observation stay provided from May 
14, 2020, to May 17, 2020. 
 
You asked the Plan to waive the copayment for the observation stay. You say that you do not understand why 
the Plan did not fully pay for the services. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing 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 $275 
copayment for in-network outpatient hospital observation services.  
 
You have been asked to pay a $275 copayment for the observation stay. The observation stay falls within the 
Outpatient hospital 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 the 
observation stay provided from May 14, 2020, to May 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this claim should be paid because 
the physician ordered this equipment for the enrollee to use during and after surgery. The Plan denied your 
request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on August 10, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for outpatient hospital 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 hospital services provided on August 
10, 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 dental services with dental code D2950 provided on June 
30, 2020. 
 
You asked the Plan to pay for dental code D2950. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the 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, dental code D2950 is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services with 
dental code D2950 provided on June 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for myocardial imaging (78431) provided on July 31, 2020. 
 
You asked the Plan to pay for myocardial imaging. You say that this is not a duplicate. The Plan denied your 
request. The Plan says this was previously billed and paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that an additional unit of CPT code 78431 is not supported in the medical record. The medical record 
only supports one unit of CPT code 78431, which was previously billed and paid. Based on this information, 
we decided that Medicare rules for coverage of myocardial imaging have not been met. Therefore, we decided 
that the Plan does not have to pay for myocardial imaging (78431) provided on July 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on May 14, 2020, 
through June 25, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because 
this service is not for durable medical equipment and it was not delivered to the member's home. The Plan 
denied your request. The Plan says this code is not recognized for out-of-network providers. 
 
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 S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) 
provided on May 14, 2020, through June 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the wrist brace provided on June 22, 2020. 
 
You asked the Plan to waive the coinsurance for the wrist brace. You say that you need assistance with your 
bills. You say you have never had a large health insurance claim. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing 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 20% 
coinsurance for in-network Medicare-covered benefits. 
 
You have been asked to pay $6.61 which is 20% of the allowed amount for the wrist brace. The allowed 
amount is $33.01. ($33.01 x 20% = $6.61). The wrist brace falls within the 'Durable Medical Equipment 
(DME) and Related 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 coinsurance for the wrist 
brace provided on June 22, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 30, 
2020. 
 
You asked the Plan to pay for the practitioner service. You say that that the enrollee was not enrolled in hospice 
at the time the services were provided. The Plan denied your request. The Plan says the enrollees claim would 
be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the members coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 22, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent nursing 
facility care provided on May 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), 
real time with image documentation; complete (76770). 
 
You asked the Plan to pre-approve an ultrasound. You say that the enrollee needs an ultrasound. The Plan 
denied your request. The Plan says an ultrasound is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an ultrasound. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation provided to justify the study, the presence of transplant is not an 
indication for a renal ultrasound. Denial upheld 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ultrasound have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image 
documentation; complete (76770).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower 
denture (D5120) provided on August 10, 2020. 
 
You asked the Plan to pay for the dental items. You say that you received dentures in 2017. You say that you 
needed new dentures as your previous ones no longer fit. You say that they also got misplaced and destroyed. 
You say that you have thyroid issues and can hardly chew or swallow food. The Plan denied your request. The 
Plan says dentures are covered once every 5 plan years. The Plan also says that the frequency limit has been 
exceeded. 
 
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 frequency limit of 1 set of dentures 
every 5 plan years has been exceeded. The record shows that the Plan paid for a complete upper denture that 
you received on May 19, 2017 and a complete lower dentures that you received on October 5, 2018. Therefore, 
we decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower 
denture (D5120) provided on August 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Depo-testosterone. 
 
You asked the Plan to pre-approve the Depo-testosterone.. You say that the enrollee has been on Testosterone 
injections. The Plan denied your request. The Plan says the enrollee does not have a pharmacy benefit with the 
Plan, and the Depo-testosterone injection is covered by the pharmacy benefit. 
 
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 Depo-testosterone.  
 
Benefits for Depo-testosterone. 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 the services (S9328) provided from April 21, 2020, to July 
22, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee 
Schedule indicates that the code in question is not valid for Medicare purposes.  
 
We looked at the file and Medicare rules. Code S9328 is assigned a status indicator of  under the Physician 
Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for 
reporting of, and payment for, these services. 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 the 
services (S9328) provided from April 21, 2020, to July 22, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry home visit provided on March 2, 2020, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for podiatry home visit. 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 podiatry home visit provided on March 2, 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 nitrous oxide (D9230 x 2), crowns (D2740 x 2), core 
build up (D9250 x 2), and the pulp cap (D3120) provided on March 12, 2020. 
 
You asked the Plan to pay for the nitrous oxide, core build up and pulp cap. You say that you and your provider 
called in and were advised the services would be covered. You also say that you were not advised that the 
crowns needed prior authorization. The Plan denied your request. The Plan says the nitrous oxide is not listed 
as a covered service. The Plan says that core build up is not listed as a covered service. The Plan also says the 
pulp cap is not listed as a covered service. 
 
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 
nitrous oxide (D9230 x 2), crowns (D2740 x 2), core build up (D9250 x 2), and the pulp cap (D3120) provided 
on March 12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy services to be provided by an out of 
network provider at the in-network rate. 
 
You asked the Plan to pre-approve the physical therapy services to be provided by an out of network provider 
at the in-network rate. You say that the services are medically necessary because you will not be in the area of 
network providers when services are required. The Plan denied your request. The Plan says there is no network 
deficiency for these services. They are available out-of-network, however the out-of-network copayment will 
be applied. 
 
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 at the in-network rate 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services at the in-network rate. Therefore, we decided that the Plan does not have to 
pre-approve the physical therapy services to be provided by an out of network provider at the in-network rate.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments the SNF stay provided from April 18, 2020, to 
May 29, 2020. 
 
You asked the Plan to waive the copayments the SNF stay. You say that the member received few 
rehabilitation services while quarantined. You say the member should not be responsible for the copayments. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $0 
copayment for days 1 through 20 and a $178 copayment per day, for days 21-100.  
 
You have been asked to pay a $3,738 copayment for the SNF stay. The SNF stay falls within the ?Skilled 
nursing facility (SNF) care? benefit category. The medical record shows rehabilitation services were provided 
during the SNF stay. See chart below. 
 
Dates of Service Service Copayment 
per Day 
SNF Days Number of 
Days 
Member 
Liability 
April 18, 2020, to 
April 30, 2020 
SNF stay $0 1-13 13 $0 
May 1, 2020, to 
May 7, 2020 
SNF stay $0 14-20 7 $0 
May 8, 2020, to 
May 29, 2020 
SNF stay $178 21-41 21 $3,738 
Total     $3,738 
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 the SNF stay provided from April 18, 2020, to May 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on August 6, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you were unaware of copayments 
when you signed up for this insurance. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing 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 $200 
copayment per visit for all other outpatient diagnostic and therapeutic services and supplies, such as MRAs, 
MRIs, CT scans, PET scans, and hyperbaric oxygen therapy.  
 
You have been asked to pay a $200 copayment for the CT scan. The CT scan 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 the CT scan provided on August 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 13, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
laboratory services. 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 laboratory services provided on July 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 19, 2020, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider 
is out-of-network with the Plan and 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 the medical services provided on May 19, 2020, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on August 3, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that prior authorization should have been 
obtained by the facility. 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 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 skilled nursing services provided on August 3, 
2020 by an out of network (OON) provider.