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

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on January 7, 2019.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you should not owe anything for the services because you have secondary insurance. 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 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs on January 7, 2019. The total allowed amount is $4,316.07 and 20% of that is $863.21. You have been asked to pay the total coinsurance amount of $863.21 for Medicare Part B drugs. Medicare Part B drugs fall 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 Medicare Part B drugs provided on January 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on January 8,
2020.
You asked the Plan to pay for the dental services. You say that you will never have a standard dental cleaning
because of this condition. The Plan denied your request. The Plan says the service is 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. This service is not listed in your EOC as a covered benefit; therefore, it
is not covered. Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910)
provided on January 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from December 30,
2019 through January 1, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim
was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that you were admitted into an inpatient setting on December 31, 2019 and discharged
on January 1, 2020. You were asked to pay a $250 copayment for December 31, 2019, days 1 of your inpatient
hospital care. You were discharged on January 1, 2020 and there was no copayment charge for the day of
discharge. Per your contract there is a $250 copayment per day required for days 1-7. 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 inpatient hospital care from December 30, 2019 through January 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with
suspension sleeve (L1833, L2397) provided to the enrollee on November 6, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis
(L0650) and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 6,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit provided on November 7, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for an outpatient visit. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was 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 an outpatient visit provided on November 7, 2019
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for laboratory services provided on January
14, 2020.
You asked the Plan to waive the coinsurance for laboratory services. You say that you were informed you
wouldn't pay anything for a wellness exam. The Plan denied your request. The Plan says the coinsurance
applied 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 20%
coinsurance for laboratory tests.
You have been asked to pay $10.09, which is 20% of the allowed amount for the laboratory services. The
allowed amount is $50.46 (20% x $50.46 = $10.09). Laboratory services falls within the "Outpatient diagnostic
tests and therapeutic services and supplies" benefit category. The laboratory services are considered diagnostic
tests. 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 laboratory services provided on January 14,
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient care provided from January 1,
2020 to January 8, 2020.
You asked the Plan to waive the copayment for inpatient care. You say that this should be fully covered
because it was medically necessary. The Plan denied your request. The Plan says this processed with 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 $325
copayment for days 1-6 of each Medicare-covered inpatient stay.
You have been asked to pay a $1950 copayment for the first six days of this inpatient stay ($325 per day x 6
days = $1,950). 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 inpatient care provided from January 1,
2020 to January 8, 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 December 18,
2019.
You asked the Plan to waive the copayment for the office visit. You say that you met your maximum out-ofpocket.
The Plan denied your request. The Plan says the copayment applied 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 $30
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse
practitioner or physician's assistant or other non-physician health care professionals in an in-network
specialist's office.
You have been asked to pay a $30 copayment for the office visit. The office visit falls within the
"Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The records show that
your maximum out-of-pocket had not been met prior to the office visit. 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 December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on December 30, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
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 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 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on February 13, 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 no prior authorization was obtained.
The Plan says that the referring provider is also out-of-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 outpatient hospital services provided on February
13, 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 periodic oral evaluation and prophylaxis provided on January 27, 2020.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you have a light periodontal disease. You also say that the provider strongly recommends you receive a prophylaxis every 4 months instead of every 6 months. The Plan denied your request. The Plan says these services exceeded your benefit limit. The Plan also says that there was not contact made by you or the provider prior to the services to verify your benefit coverage.
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, oral exams and cleanings are each limited to 1 every 6 months. The record shows that you received an oral exam and cleaning on September 23, 2019 and your oral exams and cleanings benefits were then exhausted for the time period. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on January 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood smear, peripheral, interpretation by physician with
written report services coded 85060 provided on January 7, 2020.
You asked the Plan to pay for the blood smear, peripheral, interpretation by physician with written report
services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The
Plan says the services billed are not payable.
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 85060 is blood smear, peripheral, interpretation by
physician with written report.
We find that CPT code 85060 is not supported in the medical record. Specifically, this code was billed with
place of service 11 (on campus-outpatient hospital) the PC/TC indicator for this code is 8. The value 8
identifies the only payment made for the professional component of the code is for hospital inpatient. Based on
this information, we decided that Medicare rules for coverage of the blood smear, peripheral, interpretation by
physician with written report services have not been met. Therefore, we decided that the Plan does not have to
pay for the blood smear, peripheral, interpretation by physician with written report services coded 85060
provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes G0483 and 95937 provided on December 4, 2018.
You asked the Plan to pay for CPT codes G0483 and 95937. 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 as billed.
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 5 units of CPT code G0453 is not supported in the medical records provided. Medicare rules also say that providers must report services correctly. Procedures should be reported with the CPT code that describes the services performed. In this case, the CPT Code Manual definition of code 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. CPT code 95937 is not supported in the medical record. Specifically, the record shows that train of four testing was performed and this is not the appropriate code for this service. Per Medicare guidelines, it is inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. There is no separate code for train of four monitoring. Based on this information, we decided that Medicare rules for coverage of CPT codes G0483 and 95937 have not been met. Therefore, we decided that the Plan does not have to pay for CPT codes G0483 and 95937 provided on December 4, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 17, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for physician services. You say that these services were provided in a skilled nursing
facility. You say that is the facility's responsibility to obtain prior authorization. The Plan denied your request.
The Plan says no prior authorization was 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 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 on December 17,
2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the panoramic x-ray (D0330) and the upper partial
denture (D provided from August 15, 2019 to October 10, 2019 by out of network provider.
You asked the Plan to reimburse you for the dental services. You say that you were advised that the dental
office would file with your insurance for you to receive reimbursement for the services that you received. You
say that your old dentures had broken. You say that you thought the provider was going to repair them, but you
got new ones instead. You say that this was an emergency situation. You also say that none of the local
providers make or refer for dentures. The Plan denied your request. The Plan says dental services that you
receive out of network 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 services that you receive out of
network are not covered. Therefore, we decided that the Plan does not have to reimburse you for the panoramic
x-ray (D0330) and the upper partial denture (D provided from August 15, 2019 to October 10, 2019 by out of
network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory test. You say that this was a test and pathology report, and you do not understand why it was denied. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan, prior authorization was not obtained, and this service could have been provided within the Plan 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 the medical services provided on May 6, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
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 February 7, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 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 February 7, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee on October 16,
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 the provider failed to obtain a prior authorization for this service.
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
October 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on October 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for diagnostic radiology services. You say that it isn't your fault that the military base doctor sent you to a out-of-network provider. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are in-network providers available 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 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 diagnostic radiology services provided on October 17, 2019 by an out of network (OON) provider.