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

We decided that the Plan does not have to pay for the laboratory services provided on September 24, 2019 by a
non-network 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 a non-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 laboratory services provided on September 24,
2019 by a non-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on December 4, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network 
deficiency for 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on December 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for chemotherapy provided by a participating provider on February 25, 2020.
You asked the Plan to reduce the coinsurance for chemotherapy. You say that you have received two bills that are different in payment. You say that you would like this coinsurance reduced. The Plan denied your request. The Plan says the correct coinsurance 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% coinsurance for Medicare Part B prescription drugs/in-network/chemotherapy. You have been asked to pay a 20% coinsurance of the allowed amount for chemotherapy. The total allowed amount is $2,532.56. The total amount you are being asked to pay is $506.51 ($2,532.56 x 20% = $506.51). Chemotherapy falls within the Medicare Part B prescription drugs/in-network/chemotherapy 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 reduce the coinsurance for chemotherapy provided by a participating provider on February 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider 
on March 18, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available 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 services at issue in this appeal. 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 the medical services provided by an out-of-network provider on March 18, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) 
provided on May 10, 2020. 
 
You asked the Plan to waive the copayment for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied 
correctly to the service provided. 
 
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 $150 
copayment for in-network Medicare-covered outpatient hospital services.  
 
You have been asked to pay a $150 copayment for the in-network Medicare-covered outpatient hospital service 
provided. 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 magnetic resonance imaging (MRI) 
provided on May 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for BLS emergency ambulance (A0429) and ground mileage
(A0425) provided February 8, 2020.
You asked the Plan to pay for the ambulance service. You say that the enrollee was transported multiple times
on the same date of service. Run reports attached. The Plan denied your request. The Plan says the ambulance
trip record provided supports a single transport that was paid under another claim.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. The Plan follows the same rules.
We looked at the file and Medicare rules. Based on the documentation provided, it appears that the plan
previously paid for the appealed services on check date 04/13/2020. There were no other documents showing
that there was a second ambulance transportation. Based on this information, we decided that Medicare rules
for coverage of the ambulance service have not been met. Therefore, we decided that the Plan does not have to
pay for BLS emergency ambulance (A0429) and ground mileage (A0425) provided February 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray and two additional intraoral 
periapical x-rays provided on January 31, 2020. 
 
You asked the Plan to pay for the intraoral periapical x-rays. You say that you believe you are being 
overcharged. The Plan denied your request. The Plan says the benefits for this service have been satisfied and 
the frequency limitation 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, intraoral x-rays are limited to one 
procedure per calendar year. The record shows that you received four intraoral periapical x-rays on January 31, 
2020, one x-ray was covered by the Plan, and your intraoral x-rays benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the first intraoral periapical x-ray and two additional intraoral 
periapical x-rays provided on January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services you provided on July 9, 2019 and August 6, 2019.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 psychotherapy services you provided on July 9, 2019 and August 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient surgery provided on 
February 20, 2020. 
 
You asked the Plan to waive the coinsurance for the outpatient surgery. You say that you cannot afford the 
coinsurance on this bill. 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% of 
the cost for each outpatient hospital and ambulatory surgery visit.  
 
You have been asked to pay $1,132.98 which is 20% of the allowed amount for the outpatient surgery. The 
allowed amount is $5,664.91. ($1,132.98 x 20% = $1,132.98). The outpatient surgery falls within the 
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers" 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 outpatient surgery provided on February 20, 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 you do not believe it is fair that you should 
have to pay for the services. You say that you were feeling sick, and when you visited your primary care 
physician the next day, you were sent to the emergency room. You asked the Plan to reconsider their denial and 
provide coverage for the services. 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 August 8, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2783) provided on January 28, 2020. 
 
You asked the Plan to pay for the crown. You say that your dental benefits state that you have crown coverage 
at 50%, and does not clearly state the type of crown material that is covered. 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 crown 
(D2783) provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on February 18, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on February 18, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) and ground 
mileage (A0425) provided December 5, 2019. 
 
You asked the Plan to pay for the ambulance service. You say that this enrollee was transported to and from 
their doctor's office while inpatient. You are asking the plan to decide who is responsible and process the 
claims internally via a cap deduct. The Plan denied your request. The Plan says transportation to or from a 
physician's office is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor?s office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. 
Therefore, we decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) and 
ground mileage (A0425) provided December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided by an out-of-
network provider, on December 10, 2019. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you were not notified that this 
provider was out-of-network. 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 $75 
copayment for physician/practitioner services/out-of-network/specialist.  
 
You have been asked to pay a $75 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services/out-of-network/specialist 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 a specialist visit provided by an out-of-network provider, on December 10, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
February 7, 2020 to February 13, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration because this 
is a per visit claim and the services rendered were medically necessary. The Plan denied your request. The Plan 
says the provider has billed the facility claim with an inappropriate type of bill. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim 
has been submitted with an inappropriate type of bill code. Therefore, we decided that the Plan does not have to 
pay for the home health services provided to the enrollee from February 7, 2020 to February 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services (80053,84443, 
80061, 85025) provided on March 12, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment 
has been applied correctly to the services provided. 
 
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 $15 
copayment for Medicare-covered laboratory services with an in-network provider.  
 
You have been asked to pay a $15 copayment for the Medicare-covered laboratory services rendered by an  
in-network provider. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. The laboratory services include an enrollee copayment liability, as they are a separate benefit 
from an annual routine physical exam. 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 
laboratory services (80053,84443, 80061, 85025) provided on March 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig (A9282) purchased February 17, 2020, 
 
You asked the Plan to pay for the wig. You say that your wife is going through a very hard cancer treatment 
and has lost her hair. This wig gives her some home for better days ahead. The Plan denied your request. The 
Plan says these items are not covered under Medicare. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig (A9282) 
purchased February 17, 2020,
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on February 26, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 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 outpatient services provided on February 26, 2020
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract surgery provided on January 31, 2020 and February 
6, 2020. 
 
You asked the Plan to pay for the cataract surgery. The Plan denied your request. The Plan says 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. 
 
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 
cataract surgery. 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 cataract surgery provided on January 31, 2020 and February 6, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chemotherapy drug provided on 
February 7, 2020. 
 
You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that you were told this was 
approved and covered. You say that you cannot afford this amount. 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 chemotherapy drugs at an in-network specialist's office or outpatient hospital.  
 
You have been asked to pay $811.64 which is less than the standard 20% coinsurance for the chemotherapy 
drugs. The allowed amount is $4,379.09. The chemotherapy drug 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 coinsurance for the chemotherapy drug provided on February 7, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) and 
periodontal maintenance (D4910) provided on February 28, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says the services are not a covered benefit under the 
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. The services are not listed in your EOC as a covered benefit; therefore, 
the services are not covered. Therefore, we decided that the Plan does not have to pay for topical application of 
fluoride varnish (D1206) and periodontal maintenance (D4910) provided on February 28, 2020.