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

 
We decided that the Plan does not have to waive the copayment for cardiac device monitoring (93298, G2066) 
provided April 9, 2020. 
 
You asked the Plan to waive the copayment for the cardiac device monitoring. You say that you weren't aware 
of the copayment and it should be waived. 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 $50 
copayment for diagnostic testing.  
 
You have been asked to pay a $50 copayment for the cardiac device monitoring. The cardiac device monitoring 
falls within the diagnostic testing 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 
cardiac device monitoring (93298, G2066) provided April 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power wheelchair provided on March 1, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for the power wheelchair. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says you did not receive 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 power wheelchair provided on March 1, 2020 
by an out of network provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided from February 8, 2020, through 
February 11, 2020. 
 
You asked the Plan to pay for the hospital services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member?s terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital services provided from February 8, 2020, through 
February 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammogram and digital breast tomosynthesis 
rendered on June 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 the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. The file supports one unit each of code 77067 and 77063, 
which has been paid by the Plan. Based on this information, we decided that Medicare rules for coverage of 
these services have not been met. 
 
Therefore, we decided that the Plan does not have to pay for the screening mammogram and digital breast 
tomosynthesis rendered on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on 
March 16, 2020. 
 
You asked the Plan to pay for the assembly and operation of a pump. You say that you would like 
reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in 
the room through the duration of the procedure. The Plan denied your request. The Plan says payment for this 
service is the responsibility of the facility to any vendor. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier 
other than the facility or hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the assembly and operation of a pump have not been met. Specifically, payment for this service is 
included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, 
we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on 
March 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chemotherapy drugs you received on 
December 3, 2018. 
 
You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that you do not believe you 
are responsible for this amount. The Plan denied your request. The Plan says you were charged this coinsurance 
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 Medicare Part B drugs.  
 
You have been asked to pay 20% coinsurance for the chemotherapy drugs. The chemotherapy drugs fall within 
the Medicare Part B 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 drugs you received on December 3, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-ray, single image, (D0270) provided on July 
2, 2020. 
 
You asked the Plan to pay for the dental service. You say that the service should be covered. The Plan denied 
your request. The Plan says the bitewing x-ray, single image, is not listed as a covered service. The Plan also 
says services that are not listed 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 Plans 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 
bitewing x-ray, single image, (D0270) provided on July 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine provided. 
 
You asked the Plan to pay for vaccines under Medicare Part B. You say that the Plan should cover this vaccine. 
The Plan denied your request. The Plan says shingles vaccines are not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide vaccines under 
Medicare Part B. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to vaccines under 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided.  
 
Benefits for vaccines may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physical therapy services. 
 
You asked the Plan to pre-approve the physical therapy services. The Plan denied your request. The Plan says 
the services are available in Plan and the member is contractually required to obtain this service from network 
providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide services at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested 
physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit provided on May 13, 2020. 
 
You asked the Plan to pay for the home visit. The Plan denied your request. The Plan says 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 
home visit. 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 a home visit provided on May 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0481 provided on January 21, 2020. 
 
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 billed 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. 
 
In this case, the CPT Code Manual definition of code G0481 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the documentation does not 
support any evidence of an established relationship between the enrollee and the ordering physician. 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 G0481 provided on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided. 
 
You asked the Plan to waive the copayment for office visit. You say that you went in for an annual wellness 
exam so this visit should have a $0 copayment. The Plan denied your request. The Plan says the copayment 
amount you are being charged is correct. 
 
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 
copayment for in-network primary care office visit. This visit addressed a non-routine issue that goes beyond 
the annual wellness visit; therefore, the provider billed an office visit with applicable copayment in addition to 
the annual wellness visit. 
 
You have been asked to pay $20 copayment for office visit. 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 an office visit provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cardiac device monitoring (93298, G2066) 
provided July 10, 2020. 
 
You asked the Plan to waive the copayment for the cardiac device monitoring. You say that the copayment 
should be waived. 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 $50 
copayment for diagnostic testing.  
 
You have been asked to pay a $50 copayment for the cardiac device monitoring. The cardiac device monitoring 
falls within the diagnostic testing 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 
cardiac device monitoring (93298, G2066) provided July 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walk-in-tub (E1399) purchased December 4, 2019. 
 
You asked the Plan to pay for the walk-in-tub. You say that you are requesting that the plan review this claim 
and recommending help financially to support the cost of this walk-in-tub. The Plan denied your request. The 
Plan says this is a hygienic item that is not primarily medical in nature and is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the walk-in-tub (E1399) purchased December 4, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on February 13, 
2020 by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the rendering physician 
depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's 
insurance company. You also say that the services provided were medically necessary. The Plan denied your 
request. The Plan says the service was rendered by a non-participating provider. The Plan also says that prior 
authorization was not 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 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 subsequent nursing facility care provided on 
February 13, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation and periodontal maintenance provided on May 21, 2020.You asked the Plan to pay forthe periodic oral evaluation and periodontal maintenance. You saythat you weren't told that you had a limit. You say that your money is limited, and you cannot pay.The Plan denied your request. The Plan says you are responsible for any remaining charges after the annual maximum has been exhausted.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, you also have an annual maximum of $1,000. The Plan paid $1,000 toward your dental benefits provided on February 6, 2020, February 12, 2020 and February 17, 2020, which exhausted your benefit. You are responsible for any remaining charges after the annual maximum isexhausted.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation and periodontal maintenance provided on May 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean out of network office visit. You asked the Plan to pre-approveout of network providers. You say that you prefer to see the requested provider.The Plan denied your request. The Plan says the requested provider is not in network.Medicarerules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvean out of network office visit
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe breast ultrasound you had on February 13, 2020.You asked the Plan to waive the coinsurance forthe breast ultrasound. You say that you were unaware of this coinsurance because you were told all copays are $15.The Plan denied your request. The Plan says you were charged this coinsurance 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 diagnostic radiology services. You have been asked to pay 20% coinsurance for the breast ultrasound. the breast ultrasound falls within the diagnostic radiology services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe breast ultrasound you had on February 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions and preventive procedure provided on August 6, 2020.

You asked the Plan to pay for the extractions and preventive procedure. You say that you only had this dental work done so you could get hip surgery. The Plan denied your request. The Plan says your annual dental benefit limit has been reached.

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 Plan offers a combined $500 annual supplemental dental services benefit limit. The record shows that you met the annual maximum benefit while processing this claim from the August 6, 2020 date of service, and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the extractions and preventive procedure provided on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar/sacral transforaminal epidural.

You asked the Plan to pre-approve a lumbar/sacral transforaminal epidural. You say that you are in constant pain and are unable to sleep or perform routine household activities. The Plan denied your request. The Plan says you do not meet medically necessary standards.

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. There are no imaging records supporting abnormalities and no record of severe degenerative disc disease or central spinal stenosis therefore the record does not support the criteria. Based on this information, we decided that Medicare rules for coverage of a lumbar/sacral transforaminal epidural have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar/sacral transforaminal epidural.