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

 
We decided that the Plan does not have to pay for emergency room services provided on February 25, 2020. 
 
You asked the Plan to pay for the emergency room services. You say that the records provided support the 
services in dispute. The Plan denied your request. The Plan says the claim was not billed in accordance with 
CMS guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that all charges, except for therapies, telehealth 
originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance 
services are combined and reported under revenue code 0510 (clinic visit) on TOB 13X (hospital outpatient). 
 
We looked at the file and Medicare rules. The claim does not show that the services billed were combined and 
reported under revenue code 0510 on TOB 13X. Based on this information, we decided that Medicare rules for 
coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have 
to pay for emergency room services provided on February 25, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on April 
24, 2020. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the enrollee did not start 
hospice until after they were home. The Plan denied your request. The Plan says Original Medicare would be 
responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal 
condition. 
 
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 ambulance service and ground mileage provided on April 
24, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency care you received from 
April 20, 2020, to April 24, 2020. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible 
for the copayment. 
 
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 each visit for emergency care.  
 
Review of the file shows that you had two emergency room visits from April 20, 2020, to April 24, 2020. You 
have been asked to pay a $90 copayment for each visit, totaling $180. The services fall 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 the emergency care you received 
from April 20, 2020, to April 24, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to reduce the cost-sharing for Magnetic Resonance Imaging (MRI) provided on 
May 13, 2020. 
 
You asked the Plan to reduce the cost-sharing for MRI. You say that your cost-sharing should be 30% 
coinsurance, so you should only pay $69.84. The Plan denied your request. The Plan says that the cost-sharing 
amount you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay 30% coinsurance for out-of-network MRI. The allowed 
amount of the claim is $232.80, resulting in a coinsurance obligation of $69.84. 
 
The Plan says you must pay $150 copayment for MRI. Based on the Plan contract, however, you cannot be 
asked to pay more than $69.84, which is 30% coinsurance for MRI. Therefore, we decided that the Plan has to 
reduce the cost-sharing for Magnetic Resonance Imaging (MRI) provided on May 13, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the preventive procedure, posterior resin-based 
composite of three surfaces, and two anterior resin-based composites of two surfaces provided on May 19, 
2020 by an OON provider. 
 
You asked the Plan to pay more for the preventive procedure and resin-based composites. You say that no one 
advised you that this provider was no longer in-network when you went to the dentist on March 3. You also say 
that you were told the services would be covered at 100%. The Plan denied your request. The Plan says these 
services were rendered by a non-participating dentist. The Plan also says that these services were processed 
correctly according to your OON benefits. 
 
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, unspecified preventive procedure is not 
among those covered under this benefit. The contract also clearly states that you are responsible for a 55% 
coinsurance for restorations rendered by an OON provider. Restorations are limited to two procedures per 
calendar year. Therefore, we decided that the Plan does not have to pay more for the preventive procedure, 
posterior resin-based composite of three surfaces, and two anterior resin-based composites of two surfaces 
provided on May 19, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 7, 
2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford these 
charges. 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 $265 
copayment for ambulance services.  
 
You have been asked to pay a $265 copayment for the ambulance services. 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 May 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the office visit and Botox injections you 
received on March 16, 2020. 
 
You asked the Plan to waive the cost sharing for the office visit and Botox injections. You say that the costs of 
these services are significantly more than what you paid on your previous insurance. The Plan denied your 
request. The Plan says you were charged this cost sharing 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 $15 
copayment for primary care and specialist office visits and 20% coinsurance for Medicare Part B drugs.  
 
You have been asked to pay a $15 copayment for the office visit.  This matches what your Evidence of 
Coverage states you owe for office visits, so you were charged this amount correctly.  In addition, your plan 
has charged you 20% coinsurance for the Botox injections. The Medicare-allowed rate for the injections is 
$300.66, so 20% of that amount equals $60.13. This means that you have been asked to pay the correct 
amounts 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 cost sharing for 
the office visit and Botox injections you received on March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine 
reevaluation and management services and flu vaccine provided on October 31, 2019 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for the periodic comprehensive preventive medicine reevaluation and management 
services and flu vaccine. You say that you would like the plan to reconsider their denial. The Plan denied your 
request. The Plan says the services received are not a covered benefit when provided by an out of 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 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 periodic comprehensive preventive medicine 
reevaluation and management services and flu vaccine provided on October 31, 2019 by an out of network 
(OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments applied to inpatient hospital services provided 
on January 23 - January 29, 2020. 
 
You asked the Plan to waive the copayments applied to the inpatient hospital services. You say that you paid 
$500 when you were released from the hospital. You say that you were not charged the remaining $100 until 
four to five months after the services were provided. You say that this is too long for such a billing to be 
delayed. The Plan denied your request. The Plan says the copayment in dispute was appropriately applied 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 $100 
copayment each day for days 1 to 7 for Medicare-covered inpatient hospital care.  
 
You have been asked to pay a $100 copayment each day for days 1 to 7 for the inpatient hospital services. The 
inpatient hospital services fall within the Medicare-covered inpatient hospital care benefit category. You 
received 6 days of inpatient hospital care. You have been asked to pay $600 total in copayments for these 
services. 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 copayments applied to inpatient hospital services provided on 
January 23 - January 29, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the services you received on January 3, 2020, and January 10, 2020. 
 
You asked the Plan to pay for the services. You say that the services were authorized. The Plan denied your 
request. The Plan says that the services are not covered. 
 
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 provided a rationale for its denial. Without supporting 
documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the 
services you received on January 3, 2020, and January 10, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT image capture provided on March 16, 
2020. 
 
You asked the Plan to pay for the cone beam CT image capture. You say that the provider told you the only 
way to find out if the root was cracked was to do a 3 dimensional x-ray. You also say that you feel that this was 
necessary for the provider to decide between doing an extraction or infection treatment. The Plan denied your 
request. The Plan says this service is not 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, 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 cone 
beam CT image capture provided on March 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting (76377) 
provided on January 15, 2020. 
 
You asked the Plan to pay for the 3D rendering with interpretation and reporting. You say that you would like 
reconsideration based on the record submitted. The Plan denied your request. The Plan says the documentation 
submitted does not support the service billed. 
 
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 76377 is 3D rendering with interpretation and reporting 
of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation. 
 
We asked our coder 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 3D rendering with interpretation and reporting. Our 
reviewer says that CPT code 76377 does not meet criteria for billing or reimbursement consideration. Our 
reviewer found the documentation submitted was reviewed and does not indicate that CPT code 76377 was 
rendered on the billed date of service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 3D rendering with interpretation and reporting have not been met. 
Therefore, we decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting 
(76377) provided on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional resin-based composite and sales tax provided 
on September 17, 2019. 
 
You asked the Plan to pay for the additional resin-based composite and sales tax. You say that the provider told 
you that your share was more than $400.00, and you paid this after receiving the services. The Plan denied your 
request. The Plan says this service exceeds the frequency allowed within the time period. The Plan also says 
that sales tax is not a covered benefit. 
 
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, restorations are limited to two 
procedures per calendar year. The record shows that you received three resin-based composites on September 
17, 2019, two of which were covered by the Plan, and your restorations benefit had been exhausted. Therefore, 
we decided that the Plan does not have to pay for the additional resin-based composite and sales tax provided 
on September 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PET scan provided on March 30, 2020. 
 
You asked the Plan to pay for the PET scan. The Plan denied your request. The Plan says the services were not 
billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that LCA A53132 provides a list of covered ICD-10 
codes that are appropriate to bill for a PET scan for solid tumor.  
 
We looked at the file and Medicare rules. The PET scan was billed with diagnosis codes C82.90 and R59.0. 
These diagnosis codes are not listed as covered codes, and thus are inappropriate to bill for the requested PET 
scan. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been 
met. Therefore, we decided that the Plan does not have to pay for the PET scan provided on March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for specialist services provided on January 
15, 2020 with an out-of-network provider. 
 
You asked the Plan to reduce the cost sharing for the specialist services. You say that this should only have a 
$45 copayment. The Plan denied your request. The Plan says the provider of these specialist services is an out-
of-network provider, so you were properly assessed a $70 copayment. 
 
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 $70 
copayment for out-of-network specialist services.  
 
You have been asked to pay a $70 copayment for the specialist services. The provider of these services is not a 
network provider. 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 reduce the cost sharing for specialist services provided on 
January 15, 2020 with an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hospital outpatient clinic visit and blood tests (85610) provided on May 4, 2020, to May 21, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe hospital outpatient clinic visit and blood tests. You say that you were told no authorization was required.The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied.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 forthe hospital outpatient clinic visit and blood tests (85610) provided on May 4, 2020, to May 21, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and shaving of epidermal or dermal lesion 
services provided on May 20, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit and shaving of epidermal or dermal lesion services. You say that 
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
received are not a covered benefit when provided by an out of 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 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 office visit and shaving of epidermal or dermal 
lesion services provided on May 20, 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 problem focused limited oral evaluation (D0140) 
provided on June 17, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you had an abscess and 
infection. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your 
benefit 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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on April 23, 2020, and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on June 17, 2020.