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

We decided that the Plan has to pay forthe inpatient hospital services provided from November 1, 2019 November 9, 2019.You asked the Plan to pay forthe inpatient hospital services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says that the services are not covered as billed.The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided.We find that 8 units of inpatient hospital care are supported in the medical record. In this case, the medical records show that the enrollee admitted to acute care from November 1, 2019, through November 9, 2019. The Plan says that the claim submitted for payment was for dates of service November 1, 2019, through November 8, 2019 and that only 7 days/units should be paid. However, the medical records clearly show that the enrollee did not discharge until November 9, 2019. Though the provider incorrectly billed the discharge date on the claim, the Plan is denying on the basis of days/units billed. The provider billed 8 days/units and the medical records provided show that there were 8 total days of inpatient hospital carefrom November 1, 2019, through November 9, 2019. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital services have been met.Therefore, we decided that the Plan has to pay forthe inpatient hospital services provided from November 1, 2019 November 9, 2019.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 Planhas 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled services provided to the enrollee from January 25, 
2020, to January 31, 2020. 
 
You asked the Plan to pay for this service for the enrollee. You say that these services should be covered by the 
Plan. The Plan denied your request. The Plan says neither the Plan nor Medicare can make payment to 
providers who are not eligible to take Medicare payment or who have opted out of the Medicare program. 
 
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 has opted out of the program. This 
provider is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for 
skilled services provided to the enrollee from January 25, 2020, to January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the diabetic shoes purchased on February 24, 2020, 
from an out-of-network provider. 
 
You asked the Plan to reimburse for the diabetic shoes. You say that you should be reimbursed because these 
are the only shoes you could wear and have been wearing them for over twenty years now. The Plan denied 
your request. The Plan says there is no evidence that you were unable to purchase the orthopedic shoes 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 reimburse 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 reimburse for these items/services. 
Therefore, we decided that the Plan does not have to reimburse for the diabetic shoes purchased on February 
24, 2020, from an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on April 29, 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 procedure code 71045 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 71045 and 32555. Code 71045 is a column II code with a 
modifier indicator of 1 when billed with column I code 32555. Code 71045 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest 
x-ray rendered on April 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the nuclear stress test and related drug 
supplies you received on January 7, 2020. 
 
You asked the Plan to waive the coinsurance for the nuclear stress test and related drug supplies. You say that 
the doctor's staff assured you that you would owe nothing for this service.  You also stated that this service was 
unnecessary. The Plan denied your request. The Plan says you were charged this amount correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 40% 
coinsurance for outpatient diagnostic tests and related supplies.  
 
You have been asked to pay 40% coinsurance for the nuclear stress test and related drug supplies. The nuclear 
stress test and related drug supplies falls within the outpatient diagnostic tests 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 nuclear stress test and related drug supplies 
you received on January 7, 2020.  
 
Your complaint about the provider?s office providing you with information about not owing cost sharing and 
performing unnecessary procedures is not a valid appeal for medical coverage. This part of your complaint is a 
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types 
of complaints.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waivethe $350 copayment for emergency transport provided on April 20, 2020.You asked the Plan to waivethis copayment. You say that you had a health issue in the care. The Police recommended you go to the hospital and you were taken by the emergency responders. You state you were not transported in an ambulance.The Plan denied your request. The Plan says this copayment was charged based on the cost share for emergency transport.The Plan must follow Medicare rules. Medicare pays for emergency transport when required. The Plan paid its share of the cost of this transport. This copayment is a contractual obligation you agreed to pay when you became a member of the Plan. Therefore, we decided that the Plan does not have to waivethe $350 copayment for emergency transport provided on April 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $350 copayment charged for ambulance transport 
provided March 5, 2020. 
 
You asked the Plan to waive this copayment. You say that you would like the Plan to waive this copayment. 
The Plan denied your request. The Plan says this copayment is a contractual obligation. 
 
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 $350 
copayment for ambulance transport. 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 $350 copayment charged for ambulance 
transport provided March 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant supported crown provided on June 9, 2020 by an 
OON provider. 
 
You asked the Plan to pay for the implant supported crown. You say that you contacted the Plan to find a 
dental provider in your area that could help you, but no providers were found. The Plan denied your request. 
The Plan says no coverage or benefits are available when the services are provided by a dentist who does not 
participate in the Plan's network. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the implant 
supported crown provided on June 9, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waivethe copayment of $182.69 charged for ambulance transport provided on February 27, 2020.You asked the Plan to waivethis copayment. You say that you do not believe you owe thiscopayment.The Plan denied your request. The Plan says the copayment charged is actually less than the normal copayment expectation.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 $300 copayment for ambulance transport. In this case you are being asked to pay less than your normal $300 contract price with the Plan. This cost sharing isa contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waivethe copayment of $182.69 charged for ambulance transport provided on February 27, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on November 4, 2018. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until April 3, 2020. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the services provided on November 4, 2018.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant 360 genetic testing provided on October 1, 
2019. 
 
You asked the Plan to pay for the Guardant 360 genetic testing. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, Medicare guidelines say when billing for the Guardant360 molecular lab panel, procedure code 
81479 is the only code available for billing. Based on this information, we decided that Medicare rules for 
coverage of the Guardant 360 genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the Guardant 360 genetic testing provided on October 1, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic cancer risk analysis provided on December 11, 
2019. 
 
You asked the Plan to pay for the cancer risk analysis. You say that this was ordered by a network provider and 
there is no way for the enrollee to control where the sample is sent. The Plan denied your request. The Plan 
says this is a screening test ordered by an out of network provider. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
This testing was performed in the absence of a personal history of cancer or any signs or symptoms of cancer. 
The only diagnosis reported is a family history of prostate cancer. This means that this testing was provided for 
screening purposes and a genetic cancer risk screening is not among the screening tests which Medicare covers. 
 
 
Therefore, we decided that the Plan does not have to pay for the genetic cancer risk analysis provided on 
December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $45 copayment for a tele-medicine specialist visit on June 
19, 2020. 
 
You asked the Plan to waive this copayment. You say that you were not happy with the encounter and feel you 
should not have to pay the copayment. The Plan denied your request. The Plan says this copayment was 
applied based on your 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 $45 
copayment for specialist 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 $45 copayment for a tele-medicine specialist visit on June 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chest computed tomography (CT) scan 
you had on July 7, 2020, at an outpatient hospital facility. 
 
You asked the Plan to waive the copayment for the chest CT scan. You say that you were not aware that if you 
had this scan at another location that you cost sharing would be less.  You say that you went to the facility that 
your doctor told you to go to. The Plan denied your request. The Plan says you were charged this copayment 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for advanced imaging services you have in an outpatient hospital setting.  
 
You have been asked to pay a $50 copayment for the chest CT scan. You had this CT scan at an outpatient 
hospital facility. 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. The 
Plan clearly disclosed this cost sharing to you in the Evidence of Coverage, so it is your obligation to review 
the cost sharing structure before receiving services. Therefore, we decided that the Plan does not have to waive 
the copayment for the chest computed tomography (CT) scan you had on July 7, 2020, at an outpatient hospital 
facility.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe CT colonography, screening, including image postprocessing (CPT Code 74263) provided on July 9, 2020.You asked the Plan to pay forthe CT scan. You say that you had the service due to fear. You state you had an operation and lost 10 inches of colon due to a colonoscopy procedure gone wrong and due to your negative experience in the past, you do not feel comfortable or safe having a normal colonoscopy procedure rendered.The Plan denied your request. The Plan says the service is not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. The evidence is inadequate to conclude that CT colonography is an appropriate colorectal cancer screening test. The CT colonography for colorectal cancer screening remains noncovered.Therefore, we decided that the Plan does not have to pay forthe CT colonography, screening, including image postprocessing (CPT Code 74263) provided on July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not haveto pay forthe limited oral evaluation (D0140) and the pulp vitality test (D0460) provided on February 12, 2020.You asked the Plan to pay forthe dental services. You say that you received a letter stating that the claim had been processed incorrectly. You also say that you have not received a correction.The Plan denied your request. The Plan says there is a $100 deductible for covered dental services. The Plan says that the limited oral evaluation is a covered service however, the deductible has not been reached. The Plan also says that pulp vitality test 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 coverageand limited oral evaluation is a covered service, thedeductible had not been met at the time you received the service. This cost sharing is a contractual obligation that cannot be waived. Additionally, the pulp vitality test is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140) and the pulp vitality test (D0460) provided on February 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on June 8, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you contacted the Plan 
prior to receiving this service, and were told that this service should be fully covered. The Plan denied your 
request. The Plan says this service exceeds the frequency limitation in your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on January 14, 2020, and you problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on June 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the 20% coinsurance charged for Medicare Part B drugs 
provided from January 13, 2020, to June 2, 2020  
 
You asked the Plan to waive this coinsurance. You say that you do not believe this coinsurance is correct. The 
Plan denied your request. The Plan says the Plan contract lists the coinsurance.  The Plan states that in 2019 
this benefit did not require a cost share however an Annual Notice of Change (ANOC) advising of the benefit 
changes for the year of 2020 indicated a 20% cost share will apply for each Medicare-covered chemotherapy 
drug and the administration of that drug. 
 
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 Medicare Part B drugs. 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 20% coinsurance charged for Medicare Part B 
drugs provided from January 13, 2020, to June 2, 2020
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe speech therapy services you received on March 4, 2020.You asked the Plan to waive the copayment forthe speech therapy services. You say that you were told that the copayment would only be $15.  You also stated that therapy has been discontinued because you cannot afford it.The Plan denied your request. The Plan says there are no phone records showing you were told these services would have a $15 copayment.  The Plan says that you were charged this copayment correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each speech therapy visit. You have been asked to pay a $40 copayment for the speech therapy services. 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 forthe speech therapy services you received on March 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance ($116.04) charged for a Medicare Part B 
injection provided on June 17, 2020. 
 
You asked the Plan to waive this coinsurance. You say that you had this service last year and it was covered in 
full. The Plan denied your request. The Plan says this coinsurance was charged based on your Plan contract 
agreement. The Plan also notes that the medical records and claim records show you had this service last year 
on September 17, 2019 and you were charged $111.00. 
 
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 10% 
coinsurance for Medicare Part B injections. 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 ($116.04) charged for a 
Medicare Part B injection provided on June 17, 2020.