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

 
We decided that the Plan does not have to waive the copayment for the visit with an orthopedist you had on 
July 29, 2020. 
 
You asked the Plan to waive the copayment for the visit with an orthopedist. You say that the person at the 
front desk of the doctor's office said there was no copay. You also said that the doctor did not help you. 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 $40 
copayment for visits with a specialist.  
 
You have been asked to pay a $40 copayment for the visit with an orthopedist. This copayment applies 
regardless of the outcome of the visit. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the visit with an 
orthopedist you had on July 29, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on July 1, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you did not go to the 
emergency room on this date. The Plan denied your request. The Plan says the correct copayment has been 
applied. The Plan says that stitches were removed on the date of service in question. 
 
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 emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls 
within the emergency care 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 
emergency room visit provided by a participating provider on July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services (97026) provided February 10, 2019 to
February 22, 2019.
You asked the Plan to pay for the acupuncture services. You say that these services were medically necessary.
The Plan denied your request. The Plan says the services at issue are not eligible for coverage.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have
to pay for acupuncture services (97026) provided February 10, 2019 to February 22, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory tests (87150, 87481, 87491, 87500, 87529, 
8759187640, 87641, 87651, 87653, 87661, 87798, 87801) provided on February 19, 2020. 
 
You asked the Plan to pay for lab tests. You say that these tests were medically necessary. The Plan denied 
your request. The Plan says these tests were screening services. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, lab tests, was requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory 
tests (87150, 87481, 87491, 87500, 87529, 8759187640, 87641, 87651, 87653, 87661, 87798, 87801) provided 
on February 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided.  
 
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. 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on August 13, 
2020. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that your benefits include a $0 
copayment on labs. The Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for lab services at an in-network outpatient hospital.  
 
You have been asked to pay $21.39, which is less than the standard $35 copayment for laboratory services. 
Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit 
category. The records show the laboratory services were billed by the 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 copayment for laboratory services provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services rendered on May 15, 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 procedure code 64415 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 64415 is injection(s), anesthetic agent(s) and/or steroid; 
brachial plexus. 
 
We find that CPT code 64415 is not supported in the medical record. Specifically, the records show that an 
axillary nerve block was performed and there is a more appropriate code for these services. 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 injection services rendered on May 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker ordered from the internet.
You asked the Plan to pay for this equipment. You say that the Plan should pay for this walker. The Plan
denied your request. The Plan says you did not have prior authorization for out of network durable medical
equipment. The Plan says that you ordered this equipment online from a provider who is not a Medicare
eligible provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a provider who is not eligible to take Medicare payment. The rules
say that Plans can require prior authorization and can require enrollees to use network providers. The Plan
contract states that durable medical equipment requires prior authorization and cannot be obtained out of
network.
You ordered a walker from an online provider who is not a Medicare eligible provider. You did not have prior
authorization and this provider is not in network. Therefore, we decided that the Plan does not have to pay for a
walker ordered online on May 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic shoes (L3230) and foot orthotics (L3001). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthopedic shoes and orthotics) are only 
covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these 
same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthopedic shoes and orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of 
orthopedic shoes and orthotics for your condition. Therefore, we decided that the Plan does not have to pre-
approve orthopedic shoes (L3230) and foot orthotics (L3001).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) of the spinal canal 
(72148) provided on July 10, 2020. 
 
You asked the Plan to pay for a MRI of the spinal canal. You say that the enrolle had multiple exams. The Plan 
denied your request. The Plan says only one unit is supported in the record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that an additional unit of CPT code 72148 are not supported in the medical record. The medical record 
only supports one unit of CPT code 72148, which was previously billed and paid. Based on this information, 
we decided that Medicare rules for coverage of a MRI of the spinal canal have not been met.  Therefore, we 
decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) of the spinal canal (72148) 
provided on July 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 14, 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 was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on May 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the medical services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services can be performed by an in-network provider. 
 
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 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-approve 
the medical services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee scooter. 
 
You asked the Plan to pre-approve the knee scooter. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says this is not a covered item. 
 
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 pre-approve the knee scooter.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided April 2, 2020 to April 8, 
2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan 
denied your request. The Plan says that the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the services were medically necessary. Our physician reviewer found the enrollee presented to the 
emergency department (ED) and was found to have multiple face and rib fractures and subdural hematoma. He 
had bilateral wrist fractures and underwent surgical repair. The records support that, at the time of the 
admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided April 2, 2020 to April 8, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy services provided from January 22, 
2020 to April 22, 2020. 
 
You asked the Plan to pay for home infusion therapy. You say that you were told that this code would be 
reimbursed. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because this code is not valid for Medicare purposes and is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code S9328 is not valid for Medicare 
purposes and is not payable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for home infusion therapy services provided from January 22, 2020 to April 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interim partial upper denture (D5812) provided on March 
6, 2020. 
 
You asked the Plan to pay for the dental item. You say that this item was covered in 2019. You say that the 
provider reimbursed her 50%. You say that you were not notified that this service would not be covered in 
2020. You say that the 2020 Benefit Change notification did not include any reference to this item being 
eliminated. You also say that you are disappointed that this could not be resolved with one of the many time 
consuming phone calls that were made. The Plan denied your request. The Plan says the interim partial denture 
is not listed as a covered service. The Plan also says that the Annual Notice of Changes states the list of 
services covered by your plan has changed, please see your Evidence of Coverage for a full list of covered 
services. 
 
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 
interim partial upper denture (D5812) provided on March 6, 2020.  
 
 
 
Your complaint about not being able to resolve the issue during the many time consuming phone calls 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7210 x 4) provided on July 30, 2020. 
 
You asked the Plan to pay for the dental services. You say that you pay extra to have $1,000 extra to pay for 
dental. You say that you understand that preventive dental services are not included in the $1,000. You also say 
that you thought you had $1,000 plus preventive services. The Plan denied your request. The Plan says there is 
an annual maximum of $1,000 for covered dental services. The Plan says that 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, the annual maximum has been 
exceeded. The record shows that the plan reprocessed this claim and applied $194 towards the services, thus 
exhausting the annual maximum. Additionally, the Evidence of Coverage clearly states that any amount over 
the annual maximum is your responsibility. Therefore, we decided that the Plan does not have to pay for the 
extractions (D7210 x 4) provided on July 30, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the Pelvis (72197). 
 
You asked the Plan to pre-approve this service. You say that an MRI is medically necessary for the enrollee. 
The Plan denied your request. The Plan says that an MRI is not reasonable and necessary for the diagnosis and 
treatment of the patient.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that an 
MRI of the Pelvis is medically necessary. Our physician reviewer found that an MRI is needed for staging as 
the patient will have surgery as one of his options. The test is medically necessary for critical decision making 
and is indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI) of the Pelvis (72197).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mammography services provided to the enrollee. 
 
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 service is not allowed when performed at this place of treatment. The Place of 
service code reported is not allowed. The Plan states a corrected claim would be reviewed but has not been 
received.  
 
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 Place of Service code reported 
is invalid. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan 
does not have to pay for mammography services provided to the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on
June 16, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER to get a COVID-
19 test because you were feeling ill. You were diagnosed with a cold. 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 $90
copayment for emergency room services.
Records show that you went to the ER and were examined and had a chest x-ray. You received services beyond
COVID-19 testing. You have been asked to pay a $90 copayment for the ER visit. This copayment applies
regardless of the reason for the visit. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room
(ER) visit you had on June 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) provided on June 
29, 2020. 
 
You asked the Plan to pay for the incisional biopsy of oral tissue. You say that it was not brought to your 
attention that you were seen by an out-of-network provider, or that there would be any excessive out-of-pocket 
charges. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 
plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
incisional biopsy of oral tissue (D7286) provided on June 29, 2020.