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

 
We decided that the Plan does not have to waive the copayments for the ambulance transports provided on 
January 17, 2020 and February 2, 2020. 
 
You asked the Plan to waive the copayments for the ambulance transports. You say that you would like these 
charges to be forgiven. The Plan denied your request. The Plan says that the cost share was 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 $220 
copayment for each one-way Medicare-covered ground trip.  
 
You have been asked to pay a $220 copayment for each of the ambulance transports. The ambulance transports 
fall within the one-way Medicare-covered ground trip 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 
copayments for the ambulance transports provided on January 17, 2020 and February 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal diagnostic ultrasound (76700) provided on October 31, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the diagnostic testing. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. Non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 abdominal diagnostic ultrasound (76700) provided on October 31, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483, 80157, 80159, 80162, 80173, 
80177, and 80201 provided on December 16, 2019. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services rendered 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. 
 
We find that CPT codes G0483, 80157, 80159, 80162, 80173, 80177, and 80201 are not supported in the 
medical record. Specifically, the documentation submitted did not include a valid physician order/lab 
requisition form or medical records stating exactly what tests were to be performed. The submitted laboratory 
requisition form indicates that a Chronic Care Management Profile Panel was requested. The submitted 
documentation does not itemize what tests are included in this panel. Based on this information, we decided 
that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing coded G0483, 80157, 80159, 80162, 80173, 80177, and 80201 
provided on December 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the amalgam provided on June 8, 2020. 
 
You asked the Plan to pay for the amalgam. You say that you did not know this was only a preventive dental 
policy. You say that you would have signed up for the additional benefits. The Plan denied your request. The 
Plan says the service is not a covered benefit. 
 
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 
amalgam provided on June 8, 2020.  
 
Your complaint about being misled 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunologic services (95199) provided on February 20, 
2020. 
 
You asked the Plan to pay for immunologic services. You say that this should be covered. The Plan denied 
your request. The Plan says this code is not supported. 
 
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 95199 is unlisted allergy/clinical immunologic service or 
procedure. 
 
We find that CPT code 95199 is not supported in the medical record. Specifically, the submitted medical 
records do not clearly document what services this unlisted code is being used to report. Based on this 
information, we decided that Medicare rules for coverage of immunologic services have not been met. 
Therefore, we decided that the Plan does not have to pay for immunologic services (95199) provided on 
February 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 23, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. The records provided do not contain 
documentation of the ordering physician?s intent that the tests be performed. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on January 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair lift. 
 
You asked the Plan to pay for a stair lift. You say that you needed the stair lift because it was becoming 
increasingly difficult to reach the next level of your home, eventually becoming almost impossible. You say 
that you discussed the purchase of the stair lift with the Plan and you were advised to submit a referral for 
reimbursement. You stated that you submitted the referral and the Plan subsequently denied it. You say that the 
denial of the stair lift is not logical as the equipment is necessary for you to properly live in your home. You 
asked the Plan to reconsider their decision and provide coverage. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair lift.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency department visit (99285) 
from August 18 to August 20, 2019. 
 
You asked the Plan to waive the copayment for an emergency department visit. You say that your copayment 
should be waived because you were admitted to the hospital as a result of your emergency department visit. 
The Plan denied your request. The Plan says the correct coinsurance was 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 $90 
copayment for each emergency room visit. The contract also says that you do not pay this amount if you are 
admitted to the hospital for inpatient care within 24 hours for the same condition. 
 
You have been asked to pay a $90 copayment for an emergency department visit. An emergency department 
visit falls within the Emergency Care benefit category. You were not admitted for inpatient care. 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 an emergency department visit (99285) from August 18 to August 
20, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 3, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. The records provided do not contain 
documentation of the ordering physician?s intent that the tests be performed. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a physician office visit (99212) on 
February 14, 2020. 
 
You asked the Plan to waive the copayment for a physician office visit. You say that you were not advised in 
advance of the copayment. The Plan denied your request. The Plan says the correct copayment was 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 $15 
copayment for services obtained from a primary care provider.  
 
You have been asked to pay a $15 copayment for a physician office visit. A physician office visit falls within 
the "Physician/Practitioner Services, Including Doctor?s Office Visits" 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 physician office visit (99212) on February 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the power wheelchair provided on March 
31, 2020. 
 
You asked the Plan to waive the coinsurance for the power wheelchair. The Plan denied your request. The Plan 
says that the cost sharing 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 20% 
coinsurance for durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a 20% coinsurance for the power wheelchair. The power wheelchair falls within 
the durable medical equipment (DME) and related supplies benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for the power wheelchair provided on March 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded G0483, 80177, 80157, 80159,
80173, 80162, and 80201 provided on December 5, 2019.
You asked the Plan to pay for the laboratory services coded G0483, 80177, 80157, 80159, 80173, 80162, and
80201. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan
says the services rendered are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes G0483, 80177, 80157, 80159, 80173, 80162, and 80201 are not supported in the
medical record. Specifically, the documentation submitted did not include a valid physician order/lab
requisition or medical records stating exactly what tests were to be performed. Based on this information, we
decided that Medicare rules for coverage of the laboratory services coded G0483, 80177, 80157, 80159, 80173,
80162, and 80201 have not been met. Therefore, we decided that the Plan does not have to pay for the
laboratory services coded G0483, 80177, 80157, 80159, 80173, 80162, and 80201 provided on December 5,
2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 11, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the billed CPT codes are not supported in the medical record. Specifically, the services were billed 
as if the specimen was collected by blood sampling. However, the records show that the specimen was 
collected by urine sample. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on December 11, 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-of-
network provider on January 13, 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 January 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on December 20, 2019. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not include a physician order, lab requisition, or medical records stating exactly which tests were to be 
performed and some of the tests billed do not match the specimen type for testing. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on December 20, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on February 3, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
services provided on February 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a thoracotomy (32124) provided on November 22, 2019. 
 
You asked the Plan to pay for a thoracotomy. You say that this is supported in the records. The Plan denied 
your request. The Plan says this is not documented. 
 
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 32124 is thoracotomy; with open intrapleural 
pneumonolysis. 
 
We find that CPT code 32124 is not supported in the medical record. Specifically, the submitted medical 
records do not contain documentation that a thoracotomy with open intrapleural pneumonolysis was performed. 
Based on this information, we decided that Medicare rules for coverage of a thoracotomy have not been met. 
Therefore, we decided that the Plan does not have to pay for a thoracotomy (32124) provided on November 22, 
2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee on January 20, 
2020. 
 
You asked the Plan to pay for the medical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the provider is not a network provider and the member self-directed for 
services through their non-participating nursing 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 the medical services provided to the enrollee on 
January 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the power wheelchair provided on April 
30, 2020. 
 
You asked the Plan to waive the coinsurance for the power wheelchair. The Plan denied your request. The Plan 
says that the cost sharing 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 20% 
coinsurance for durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a 20% coinsurance for the power wheelchair. The power wheelchair falls within 
the durable medical equipment (DME) and related supplies benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for the power wheelchair provided on April 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 27, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for genetic testing. You say that the enrollee's physician ordered this testing during
the course of treatment. The Plan denied your request. The Plan says the denial of payment for these services is
correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network
with the Plan.
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 August 27, 2019
by an out of network (OON) provider.