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

We decided that the Plan does not have to waive the copayment for arthrocentesis and does not have to waive
the coinsurance for a Medicare Part B drug injection provided on December 20, 2019.
You asked the Plan to waive the copayment for arthrocentesis and to waive the coinsurance for a Medicare Part
B drug injection. You say that you were told that you needed the injections in order to have surgery and were
not informed of the additional cost. 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 $295
copayment for surgery services provided in an outpatient hospital facility. Your contract with the Plan also
clearly says that you must pay 20% coinsurance for Medicare Part B drugs.
You received arthrocentesis on December 20, 2019 at an out-of-network provider. Arthrocentesis is considered
an outpatient surgical procedure. Therefore, you are responsible to pay the $295 copayment.
You received a Medicare Part B drug on December 20, 2019. The allowed mount is $1,125.22 and 20% of that
is $225.04.
The total amount you owe is: $520.04.
You have been asked to pay the total amount of $520.04 for arthrocentesis and a Medicare Part B drug
injection. Arthrocentesis falls within the outpatient surgery, including services provided at hospital outpatient
facilities and ambulatory surgical centers benefit category. A Medicare Part B drug injection falls within the
Medicare Part B prescription drugs 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
arthrocentesis and does not have to waive the coinsurance for a Medicare Part B drug injection provided on
December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second duplex scan (CPT 93970) provided to the enrollee 
on August 7, 2019. 
 
You asked the Plan to pay for the second scan. You say that this should be paid for. The Plan denied your 
request. The Plan says there is no additional documentation supporting an additional study, which was billed 
and remains denied. 
 
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 93970 is "Duplex scan of extremity veins including 
responses to compression and other maneuvers." 
 
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 pay for the second scan. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found there is 
no documentation provided suggesting that additional billable work was completed beyond the covered duplex 
of 8/7/2020. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the second scan have not been met. Therefore, we decided that the Plan does not 
have to pay for a second duplex scan (CPT 93970) provided to the enrollee on August 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided November 22, 
2019 to January 8, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically 
necessary. The Plan denied your request. The Plan says services could have been provided in the observation 
setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee had an infection. Antibiotics should provide a positive response in less 
than two midnights. There was no signs of a complicated infection at the time of admission to warrant inpatient 
status. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided November 22, 2019 to January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manual therapy and mechanical traction therapy provided 
from February 25, 2020 to March 3, 2020. 
 
You asked the Plan to pay for chiropractic services. You say that you have always been covered for these 
services in the past. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor. 
 
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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for manual therapy and mechanical traction therapy provided from February 25, 
2020 to March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on February 13, 
2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you have never paid $10 for blood 
work and normally your specialist visit is a different amount. You say you should not be charged to see a nurse 
practitioner when you intended to see your primary care doctor. 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 $10 
copayment for each primary care visit.  
 
You have been asked to pay a $10 copayment for the office visit. The office visit falls within the Physician/ 
Practitioner services, including doctor's office visits benefit category. The record shows that you were 
charged for a primary care office visit and the provider is a family practice provider. 
 
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 office visit provided on February 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you have rash and poor circulation 
and need the stockings. The Plan denied your request. The Plan says these stockings are non-covered under the 
surgical dressing benefit because they do not meet the statutory definition of a dressing. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 7, 2020. 
 
You asked the Plan to pay for the dental services. You say that the dental office didn't tell you the provider was 
not participating. You say that you thought everything would be covered. The Plan denied your request. The 
Plan says out-of-network dental services are not covered benefits. 
 
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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
services provided on March 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (99100) provided September 12, 2019. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says Original Medicare is liable for payment for these services. 
 
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 anesthesia services (99100) provided September 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic parenteral drug (D9610) provided on March 
19, 2020. 
 
You asked the Plan to pay for the therapeutic parenteral drug. You say that you were aware that this provider 
was out-of-network. You also say that this was your only option because they were the only provider available 
due to businesses closing. 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 
therapeutic parenteral drug (D9610) provided on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nuclear medicine test provided on 
February 18, 2020. 
 
You asked the Plan to waive the copayment for the nuclear medicine test. You say that you do not believe you 
should be charged for this test. 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 nuclear medicine services at an in-network outpatient hospital.  
 
You have been asked to pay a $275 copayment for the nuclear medicine test. The nuclear medicine test 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 nuclear medicine test provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services and an office visit provided on October 
11, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for physician services and an office 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 these services could have been provided in-network. 
 
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 physician services and an office visit provided on 
October 11, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We are dismissing your case. The Plan agreed to pay for the office visit and drug testing. Therefore, there
is no need for a coverage decision.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on February 10, 2020. 
 
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 not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on February 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan provided on December 29, 2019. 
 
You asked the Plan to pay for the CT scan. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
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 the CT scan provided on December 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on January 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. 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 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 January 27, 2020 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 pneumatic compression device (E0675, E0673).
You asked the Plan to pay for a pneumatic compression device. You say that the device was used while you were in anesthesia in surgery. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism 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 (E0675, E0673).
You will not be held responsible for this payment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on June 5, 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 services from out-of-network providers are not covered unless pre-authorized.
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 physician services provided to the enrollee on
June 5, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient rehabilitation services and a Skilled Nursing 
Facility (SNF) stay provided from September 23, 2019 to September 28, 2019. 
 
You asked the Plan to pay for outpatient rehab and SNF care. You say that you do not agree with the Plan's 
decision to deny this admission and believe the claim should be approved. The Plan denied your request. The 
Plan says the copayment amounts you are being charged for outpatient rehabilitation are correct. The Plan also 
says that the denial of payment for the SNF stay is correct because prior authorization is required for SNF care 
but was not requested or obtained for this stay. 
 
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 $25 
copayment per provider, per date of service for outpatient rehabilitation care. For dates of service September 
24, 2019, September 25, 2019, and September 26, 2019 you have been asked to pay $25 copayment per day of 
service for outpatient rehab. For date of service September 27, 2019, you have been asked to pay the allowed 
amount of $15.90 because this is less than the $25 copayment for outpatient rehab. Your total copayment 
obligation is therefore $90.90. Your contract with the Plan also says that you must obtain prior authorization 
for Skilled Nursing Facility (SNF) care. 
 
You have been asked to pay $25 copayment or less for outpatient rehab. Outpatient rehab falls within the 
Outpatient Rehabilitation 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. You also received SNF care without requesting or obtaining prior authorization, 
therefore the Plan?s prior authorization requirements have not been met and the Plan is not required to pay for 
this service. Therefore, we decided that the Plan does not have to pay for outpatient rehabilitation services and 
a Skilled Nursing Facility (SNF) stay provided from September 23, 2019 to September 28, 2019.  
 
Please contact the in-network provider or the health plan regarding refunds for any amounts that you may have 
been charged beyond the applicable cost-sharing for these services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 3, 2020.
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 screening tests are not covered.
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 test at issue in this appeal, these services, 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 laboratory services rendered on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee on January 28,
2020.
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 the services were not referred by a network provider or rendered in a participating facility.
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 office visit services provided to the enrollee on
January 28, 2020.