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

 
We decided that the Plan does not have to waive the copayment for a hospital outpatient clinic visit (G0463) on 
March 11, 2020. 
 
You asked the Plan to waive the copayment for a hospital outpatient clinic visit. You say that you already paid 
the copayment for a specialist office visit and should not be charged a facility fee. 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 $30 
copayment for each specialist office visit. The Plan contract also says that you may be charged an additional 
fee equal to the outpatient cost-share when you visit a provider. 
 
You have been asked to pay a $30 copayment for a hospital outpatient clinic 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 a hospital outpatient clinic visit (G0463) on March 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography provided on February 25, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the CT thorax. You say that the CT scan was medically necessary. The Plan 
denied your request. The Plan says you did not request 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 computed tomography provided on February 
25, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment from $120 to $40 for the chest x-ray (71045) 
and the emergency department visit (99283) provided on April 7, 2020. 
 
You asked the Plan to adjust the copayment for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment 
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 $120 
copayment for emergency care provided.  
 
You have been asked to pay a $120 copayment for the emergency care provided. 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 adjust the copayment from $120 to $40 for the chest x-ray (71045) and the emergency department visit 
(99283) provided on April 7, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound (76775) provided on  
March 9, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $110 
copayment for each Medicare-covered radiological diagnostic service.  
 
You have been asked to pay a $108.17 copayment for the Medicare-covered radiological diagnostic service 
provided. This is the Plan allowed amount, which is less than the applicable copayment. 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 ultrasound (76775) provided on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 16, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says prior authorization was not obtained by the provider or the facility. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on April 16, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction provided on February 19, 2020. 
 
You asked the Plan to pay for the extraction. You say that you only had an extraction without anesthesia. You 
also say that the provider advised that your plan would cover the cost. The Plan denied your request. The Plan 
says the extraction was rendered by a Medicare opt out provider. The Plan also says that Medicare does not 
cover services from opt out providers unless they are urgent/emergent. 
 
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 physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. The record shows that you were made aware that you must 
see a network provider prior to these services being rendered. Therefore, we decided that the Plan does not 
have to pay for the extraction provided on February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 24, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on February 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound of the breast (76641) provided January 21, 
2020. 
 
You asked the Plan to pay for the ultrasound of the breast. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services billed are not supported by the records provided. 
 
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 76641 is not supported in the medical record. Specifically, the medical records provided 
only support one instance of the ultrasound being performed. The plan made a requested for records to support 
an additional instance and the requested documentation was not received. Based on this information, we 
decided that Medicare rules for coverage of the ultrasound of the breast have not been met. Therefore, we 
decided that the Plan does not have to pay for an ultrasound of the breast (76641) provided January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network 
(OON) provider on March 19, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan?s 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service 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 this service. Therefore, we decided that the Plan does not 
have to pay for the office visit (99214) rendered by the out of network (OON) provider on March 19, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99231) provided from November 25, 2019 to 
November 26, 2019. 
 
You asked the Plan to pay for hospital care. You say that the enrollee was no longer in hospice. The Plan 
denied your request. The Plan says Original Medicare is responsible for coverage of these services. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 21, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for hospital care (99231) 
provided from November 25, 2019 to November 26, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from March 3, 2020 to 
March 4, 2020 and from March 17, 2020 to March 25, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
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 the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from March 3, 2020 to March 4, 2020 and 
from March 17, 2020 to March 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (CPT Code 92015) provided on February 
11, 2020. 
 
You asked the Plan to pay for the eye refraction. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says the provider billed the claim incorrectly. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The notes concluded that you had a complete routine eye exam with a refraction. For February 11, 2020, the 
provider billed only the refraction in error. When a refraction is billed with a routine diagnosis, the claim is 
processed, but no payment is issued as the refraction must be billed along with a routine exam. The Plan has 
spoken to the office and requested they submit a corrected claim for your exam and refraction. Once the claim 
is processed, the provider will then update your balance for February 11, 2020 to zero. Therefore, we decided 
that the Plan does not have to pay for the eye refraction (CPT Code 92015) provided on February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and adjunctive 
procedure (D9999) provided on January 28, 2020 and May 7, 2020. 
 
You asked the Plan to pay for the complete maxillary denture and adjunctive procedure. You say that you are 
not asking for total reimbursement, but would like these services to be reconsidered. The Plan denied your 
request. The Plan says these services are not covered under your 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 
complete maxillary denture (D5110) and adjunctive procedure (D9999) provided on January 28, 2020 and May 
7, 2020.  
 
Your complaint about being taken advantage of 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdominal ultrasound (76700) provided on April 29, 
2020. 
 
You asked the Plan to pay for the abdominal ultrasound. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT Code 76770 is a component of column 
1 code 93975. 
 
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, we have confirmed that code the 
abdominal ultrasound has a bundled relationship with code 96975 and cannot be paid as billed. This code 
cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for an abdominal ultrasound (76700) provided on 
April 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral 
periapical x-ray, and endodontic therapy provided on January 30, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and 
endodontic therapy. You say that prior to the services being rendered, you found that this provider was listed as 
an in-network provider. You also say that after the services were rendered, you were advised that this provider 
had opted out of Medicare. The Plan denied your request. The Plan says the treating provider opted out of 
Medicare, effective September 13, 2016 to September 13, 2020. The Plan also says that services performed by 
a privately contracted provider are not covered. 
 
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 physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the problem focused limited oral evaluation, first intraoral periapical x-ray, and endodontic therapy provided on 
January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids you received on January 25, 2020. 
 
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says the services were 
not provided by the Plan provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when they are provided by the Plan's Hearing.  
 
We looked at the file and the Plan's rules. The hearing aids in question were not provided by the Plan's hearing 
aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have 
not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids you received on 
January 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on February 
13, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that the ambulance trip was due 
to a hit and run and you feel the other person should be responsible for the charges. 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 a $250 
copayment for ambulance services.  
 
You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the 
ambulance 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 ambulance services 
provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 8, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 May 8, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the SI joint arthrodesis provided to the enrollee on February 11, 2020. 
 
You asked the Plan to pay for the SI joint arthrodesis. The Plan denied your request. The Plan says that this is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the SI joint arthrodesis. Our reviewer says 
that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that clinical practice guidelines support minimally invasive arthrodesis of the SI joint. The 
procedure was medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SI joint arthrodesis have been met. Therefore, we decided that the Plan has 
to pay for the SI joint arthrodesis provided to the enrollee on February 11, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray (CPT 71045) provided on March 17, 2020. 
 
You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says this is a duplicate claim. 
 
The Plan must follow Medicare rules. Medicare 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 x-ray in question was billed on a duplicate claim to one 
previously processed and paid by the Plan. The records do not show that an additional x-ray was provided on 
the date of service in question. Based on this information, we decided that Medicare rules for coverage of the x-
ray have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray (CPT 71045) 
provided on March 17, 2020.