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

We decided that the Plan does not have to waive the coinsurance for an MRI provided on May 20, 2020. 
 
You asked the Plan to waive the coinsurance for an MRI. You say that you should not owe anything for an 
MRI. 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 diagnostic and therapeutic radiology services.  
 
You received an MRI on May 20, 2020. The allowed amount is $340 and 20% of that is $68.  
 
You have been asked to pay the total coinsurance amount of $68 for an MRI. An MRI falls within the 
outpatient diagnostic tests and therapeutic services and 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 an MRI provided on May 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion therapy (S9328) provided November 8, 2017 to 
December 11, 2017. 
 
You asked the Plan to pay for the infusion therapy. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this CPT code is not payable by Medicare. 
 
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 code S9328 is not supported in the medical record. Specifically, "S" codes are for use by 
private sector and Medicaid and are not payable under the Medicare program. Based on this information, we 
decided that Medicare rules for coverage of the infusion therapy have not been met. Therefore, we decided that 
the Plan does not have to pay for infusion therapy (S9328) provided November 8, 2017 to December 11, 2017.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 25, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim should be submitted to Original Medicare due the enrollee's hospice election 
at the time of service. 
 
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 
physician services provided to the enrollee on November 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 13, 
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 the submitted documentation did not contain sufficient detail to support the billed charges. 
 
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 various denied CPT codes are not supported in the medical record. Specifically, the place of 
service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The 
claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of 
a doctor's office (POS 11). Additionally, the case file does not contain a valid physician order for these 
services. 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 laboratory services provided to the enrollee 
on April 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that the member cannot bathe themselves or afford 
to purchase a shower chair on their own. You state the member is quadriplegic. The Plan denied your request. 
The Plan says a shower chair is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotics provided to the enrollee on February 19, 2020. 
 
You asked the Plan to pay for the services. You say that payment is due immediately. The Plan denied your 
request. The Plan says the provider is known for utilizing a telephonic consult to obtain the clinical information 
for durable medical equipment. 
 
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 orthotics provided to the 
enrollee on February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (G0439, G0444) provided July 10, 2020. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered. The Plan denied 
your request. The Plan says the services were not emergent or pre-authorized. There were network providers 
available. 
 
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 service 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 an office visit (G0439, G0444) provided July 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the debridement services (11012 x 2), 
repair of the finger/hand tendon (26356 x 2), and the finger fracture treatments (26735 x 2) provided on 
November 3, 2019. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the services provided. 
 
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-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay $448.43 ($2,242.15 Plan allowed amount x 20% coinsurance) for the Medicare-
covered surgery services provided at the outpatient hospital. 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 debridement services (11012 x 2), repair of the finger/hand tendon (26356 x 2), and the finger fracture 
treatments (26735 x 2) provided on November 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on May 14, 2020. 
 
You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says routine 
vision care services are only covered when performed by a participating provider. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services when provided by a participating provider. 
 
We looked at the file and the Plan's rules. The file shows that the eyewear provider at issue in this case is not a 
participating provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of 
the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for 
eyeglasses provided on May 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on June 
8, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that the doctor decided to 
move the enrollee because he was under the impression that he was at risk of falling. 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay $350 for Medicare-covered ambulance services per trip. 
 
The enrollee has been asked to pay a $350 copayment for the ambulance transport. The ambulance transport 
falls within the "Ambulance services" benefit category. The records show that the enrollee was transported by 
ambulance. This means that the enrollee has been asked to pay the correct amount based on the contract with 
the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport 
provided on June 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that this should be covered. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for a CGM to be covered, the beneficiary must 
be insulin-treated with 3 or more daily insulin injections. 
 
We looked at the file and Medicare rules. The submitted medical records do not show that the enrollee is 
insulin treated. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 
continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an CT scan provided by a non-participating 
provider on June 16, 2020. 
 
You asked the Plan to waive the copayment for an CT scan. You say that you would like this claim reprocessed 
as in-network. 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 $180 
copayment for outpatient diagnostic tests/in-network/advanced imaging services.  
 
You have been asked to pay $65.90 which is less than your copayment amount of $180 for an CT scan. The CT 
scan provided was processed as in-network; therefore, the correct copayment has been applied. An CT scan 
falls within the outpatient diagnostic tests/in-network/advanced imaging 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 an CT scan provided by a non-participating provider on June 16, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the prophylaxis (D1110), periodic oral evaluation 
(D0120), the intraoral x-rays (D0220), and the consultation for a second opinion (D9310) provided from 
January 2, 2020, to January 8, 2020 by the out of network provider. 
 
You asked the Plan to reimburse you for the dental services. You say that you contacted Medicare on May 1, 
2020. You say that you were advised you have a $2,000 allowance for dental services that you receive in and 
out of network. You also say that you were given misinformation. The Plan denied your request. The Plan says 
the provider in this case is not a network provider. The Plan also says if you choose to use a provider outside of 
the network, the services will not be 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 
prophylaxis (D1110), periodic oral evaluation (D0120), the intraoral x-rays (D0220), and the consultation for a 
second opinion (D9310) provided from January 2, 2020, to January 8, 2020 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy. 
 
You asked the Plan to pre-approve percutaneous laminotomy/laminectomy. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested services. 
 
The Plan must follow Medicare rules. Medicare rules say that percutaneous laminotomy/laminectomy is 
covered for enrollees with LSS who are enrolled in an approved clinical study. 
 
We looked at the file and Medicare rules. Review of the file does not support that the enrollee is enrolled in an 
approved clinical study. Based on this information, we decided that Medicare rules for coverage of 
percutaneous laminotomy/laminectomy have not been met. Therefore, we decided that the Plan does not have 
to pre-approve percutaneous laminotomy/laminectomy.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for physical therapy provided from June 6, 
2019, through August 1, 2019. 
 
You asked the Plan to waive the deductible for physical therapy. You say that the only alternative left was to 
try specific exercises to strengthen your bones. You say that you should be reimbursed for the expenses you 
incurred. The Plan denied your request. The Plan says the deductible applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that your deductible is $975.This is the amount you have to pay out-of-pocket 
before we will pay our share for your covered medical services. Until you have paid the deductible amount, 
you must pay the full cost for most of your covered services. Outpatient therapy from an out-of-network 
provider is not excluded from the deductible. 
 
The item or service you asked the Plan to waive the deductible for falls within the "Outpatient rehabilitation 
services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your 
$975 deductible applies to out-of-network outpatient therapy. This cost sharing is a contractual obligation that 
had not been met at the time physical therapy was received from June 6, 2019, through August 1, 2019. 
Therefore, we decided that the Plan does not have to waive the deductible for physical therapy provided from 
June 6, 2019, through August 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by you on May 24, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. 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 May 24, 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 by you on May 
24, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the $40 copayment charged for physician services provided on 
April 17, 2020. 
 
You asked the Plan to waive this copayment. You say that you were told that because you had to wear a mask, 
you would not have to pay the copayment due to the Corona virus. The Plan denied your request. The Plan says 
the copayment was charged based on the bill submitted by your provider. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $40 
copayment for outpatient mental health visits.  
 
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 $40 copayment charged for physician services provided on April 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 
16, 2020. 
 
You asked the Plan to pay for the dental service. You say that since you were a new patient, that this service 
was part of the exam. The Plan denied your request. The Plan says comprehensive oral evaluations are covered 
once every 3 plan years. The Plan says that the frequency limit 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 and comprehensive oral evaluations are 
listed as a covered service, the frequency limit of once every 3 plan years has been exhausted. The record 
shows that you received this service on November 25, 2019. Therefore, we decided that the Plan does not have 
to pay for the comprehensive oral evaluation (D0150) provided on June 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on June 
14, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that this should be covered 
by your insurance. 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 $150 per 
trip, each way.  
 
You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport falls 
within the "Ambulance services" benefit category. The records show that you were transported by ambulance. 
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 ambulance transport provided on June 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement Group 3 power wheelchair. 
 
You asked the Plan to pre-approve a replacement power wheelchair. You say that you have had multiple 
repairs done to your power wheelchair and now you would like to get a new one from a different provider. The  
Plan denied your request. The Plan says there is no documentation that your current power wheelchair cannot 
be repaired. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power wheelchair provided in December 2019. Your power wheelchair is still 
under reasonable useful lifetime and the supplier says it can still be repaired. Therefore, we decided that the 
Plan does not have to pre-approve a replacement Group 3 power wheelchair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a pelvic ultrasound received on June 3, 
2020. 
 
You asked the Plan to waive the copayment for the services. You say that the office did not waive the 
copayment for you. The Plan denied your request. The Plan says the copayment applied correctly according to 
your benefits and the services rendered. 
 
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 $25 
copayment for Medicare-covered ultrasounds.  
 
You have been asked to pay a $25 copayment for the services. The service falls within the Medicare-covered 
ultrasounds 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 pelvic ultrasound 
received on June 3, 2020.