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

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound you had. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that someone should have told 
you that there would be a charge for this ultrasound so that you would have had the opportunity to refuse it. 
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 $125 
copayment for radiological diagnostic services.  
 
You have been asked to pay $102.83 for the breast ultrasound. The allowed amount for the breast ultrasound is 
$102.83, which is less than your copayment obligation. The breast ultrasound falls within the radiological 
diagnostic 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 copayment for the breast ultrasound.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forchemotherapy provided by a participating provider on January 20, 2020, through May 14, 2020.You asked the Plan to waive the coinsurance for chemotherapy. You say that you cannot afford this coinsurance. The Plan denied your request. The Plan says the correct coinsurance has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs/in-network. You have been asked to pay a 20% coinsurance of the allowed amount for chemotherapy. The total allowed amount is $10,225.92. The total amount you are being asked to pay is $2,045.18 ($10,225.92 x 20% = $2,045.18). Chemotherapy falls within the Medicare Part B prescription drugs/in-network 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 chemotherapy provided by a participating provider on January 20, 2020, through May 14, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ER visit provided on March 15, 2020. 
 
You asked the Plan to pay for the ER visit. You say that the claim has not been paid in full or under the terms 
of the contract. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
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 the ER visit provided on March 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyewear provided on May 7, 2020. 
 
You asked the Plan to pay for eyewear. You say that your vision is very bad. The Plan denied your request. The 
Plan says the denial of additional payment for this eyewear is correct, because the Plan has already paid the full 
$150 allowance for eyewear in 2020. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $150 allowance for supplemental eyewear every year. 
 
We looked at the file and the Plan's rules. The Plan paid the full $150 allowance covered by the Plan's eyewear 
benefits, therefore you are responsible for any amount beyond this. Based on this information, we decided that 
the Plan's rules for coverage of eyewear have not been met. Therefore, we decided that the Plan does not have 
to pay for eyewear provided on May 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator (E1390) provided on April 15, 2020. 
 
You asked the Plan to pay for the oxygen concentrator. You say that you would like reconsideration because 
this is the 29th month of billing for this supply. The Plan denied your request. The Plan says no further 
payment for oxygen equipment will be made during the 5-year reasonable useful lifetime after rental payments 
are made for 36 months of continuous use. 
 
The Plan must follow Medicare rules. Medicare rules say that reimbursement for oxygen equipment is limited 
to 36 monthly rental payments. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen concentrator have not been met. Specifically, the record indicates that the billed date of 
service is the 37th month of billing for the oxygen concentrator. Therefore, we decided that the Plan does not 
have to pay for the oxygen concentrator (E1390) provided on April 15, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim must first be 
submitted to the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified the 
primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary 
insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the 
services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 9, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you received an EKG from medics 
treatment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 9, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion supplies for external drug infusion pump (A4222) 
and Hyqvia 100mg immuneglobulin injection (J1575). 
 
You asked the Plan to pay for the infusion and injection supplies. You say that please have the attached records 
reviewed. The Plan denied your request. The Plan says the records do not support the service billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician's order, proof of delivery and itemized shipping/billing invoice 
for the supplies provided in this case. Based on the physician's order, A4222 is not selected as a supply to be 
dispensed. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for infusion supplies for external 
drug infusion pump (A4222) and Hyqvia 100mg immuneglobulin injection (J1575).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 4, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician's services. 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 physician's services provided on October 4, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99283) provided on November 4, 
2018. 
 
You asked the Plan to pay for emergency room services. You say that you should not be responsible for this 
charge. The Plan denied your request. The Plan says this claim was not received within the required time 
frame. Please note that the Plan has indicated the provider is dropping the charges at issue. 
 
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 emergency room services was not filed until December 04, 2019,. 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 emergency room services (99283) provided on 
November 4, 2018.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for family psychotherapy (90847) provided on March 4, 2020. 
 
You asked the Plan to pay for the psychotherapy. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the diagnosis code billed is inconsistent 
with the procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not substantiated their denial with evidence as to why this 
diagnosis code is inappropriate for the service billed. It is the burden of the Medicare Health Plan to 
substantiate the denial with evidence. The denial is not substantiated and we must find in your favor. Therefore, 
we decided that the Plan has to pay for family psychotherapy (90847) provided on March 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab tests provided by a participating 
provider on May 20, 2020. 
 
You asked the Plan to waive the copayment for lab tests. You say that you went for your wellness exam. The 
Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
copayment for outpatient diagnostic tests/in-network/laboratory tests.  
 
You have been asked to pay a $5 copayment for lab tests. When additional services are provided outside of an 
annual wellness exam, additional copayments are applied; therefore, the correct copayment for lab work has 
been correctly applied. Lab tests falls within the outpatient diagnostic tests/in-network/laboratory tests 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 lab tests provided by a participating provider on 
May 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a nuclear stress test provided by a participating provider on February 7, 2020.You asked the Plan to waive the copayment for a nuclear stress test. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $95 copayment for outpatient diagnostic tests/nuclear medicine radiological services. You have been asked to pay a $95 copayment for a nuclear stress test. A nuclear stress test falls within the outpatient diagnostic tests/nuclear medicine radiological 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 youenrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a nuclear stress test provided by a participating provider on February 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the ostomy supplies you received from 
April 30, 2020, through June 2, 2020. 
 
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that you cannot afford this 
coinsurance. 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 prosthetic devices and related supplies.  
 
You have been asked to pay 20% coinsurance for the ostomy supplies. The ostomy supplies fall within the 
prosthetic devices 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 ostomy supplies you received from April 30, 2020, through June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on January 2, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you saw the doctor of 30 
seconds and then you left. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for physician/practitioner services/in-network/specialist.  
 
You have been asked to pay a $45 copayment for a specialist office visit. Since a specialist office visit did take 
place, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner 
services/in-network/specialist benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist 
office visit provided by a participating provider on January 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the posterior resin-based composite of four or more surfaces, 
posterior resin-based composite of three surfaces, posterior resin-based composite of two surfaces, crown, and 
core buildup, including any pins when required provided from May 19, 2020, and May 21, 2020. 
 
You asked the Plan to pay for the posterior resin-based composites, crown, and core buildup. You say that you 
sought an out-of-network dentist because you were informed the Plan would cover 50% of the costs. The Plan 
denied your request. The Plan says crown and core buildup are not covered benefits. The Plan also says that the 
Plan provides a benefit for 2 fillings per calendar year, and you do not meet the conditions of payment for 3 
additional fillings. 
 
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, crown, and core buildup, including any 
pins when required are not among those covered under this benefit. The contract also clearly states that 
composite restorations (fillings) are limited to two procedures per calendar year.  
The record shows that you received two anterior resin-based composites of three surfaces on May 21, 2020 that 
were covered by the Plan, and your composite restorations benefit has been exhausted. Therefore, we decided 
that the Plan does not have to pay for the posterior resin-based composite of four or more surfaces, posterior 
resin-based composite of three surfaces, posterior resin-based composite of two surfaces, crown, and core 
buildup, including any pins when required provided from May 19, 2020, and May 21, 2020.  
 
Your complaint about your dissatisfaction with the Plan 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a TENS unit (HCPCS E0730) provided to the enrollee on 
February 26, 2020. 
 
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 this was reported without the appropriate modifier. 
 
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 HCPCS code E0730 is "Transcutaneous electrical nerve 
stimulation (tens) device, four or more leads, for multiple nerve stimulation." 
 
We find that HCPCS code E0730 is not supported in the medical record. Specifically, this was reported with 
place of treatment code 12, and without the proper modifier to accompany. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for a TENS unit (HCPCS E0730) provided to the enrollee on February 26, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services provided to the enrollee on 
January 14, 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 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 27, 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 emergency department services provided to the enrollee on January 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 72170) provided on April 28, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a column II 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, 
the column two code is denied, and the column one code is eligible for payment. Procedure code 72170 is part 
of an edit pair with procedure code 73501. Procedure code 73501 is a column one code, and procedure code 
72170 is a column two code. Procedure code 73501 has been billed on this date of service, which means that 
procedure code 72170 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for 
the services (CPT 72170) provided on April 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (HCPCS S9328) provided to the 
enrollee from January 1, 2018 to January 22, 2018. 
 
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 this code is invalid for Medicare use. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status 
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for 
Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services 
have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy 
(HCPCS S9328) provided to the enrollee from January 1, 2018 to January 22, 2018.