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

 
We decided that the Plan does not have to pay for the medical services provided on February 6, 2019 to 
February 25, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that you were not told that you needed a referral 
and are on a fixed income. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because this provider is out-of-network with the Plan and authorization was not obtained. 
 
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 February 6, 2019 
to February 25, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided to the enrollee on February 6, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. The documentation provided does not show that the services in 
question were provided by the billing provider. 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 to the enrollee on February 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a wound therapy pump (E2402) provided 
from July 18, 2019 to August 14, 2019. 
 
You asked the Plan to waive the coinsurance for a wound therapy pump. You say that this item did not work as 
it was supposed to. The Plan denied your request. The Plan says this processed 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a $532.50 coinsurance for a wound therapy pump ($2662.52 allowed amount x 
20% = $532.50). A wound therapy pump falls within the durable medical equipment 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 a wound therapy pump (E2402) provided from July 18, 
2019 to August 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation provided on May 14, 2020. 
 
You asked the Plan to pay for the limited oral evaluation. You say that you had no other option because you 
were hurting. The Plan denied your request. The Plan says a limited exam to evaluate a problem is only 
covered once per plan year. 
 
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, you also have a maximum benefit of 
one limited oral evaluation per plan year. The Plan paid for an oral evaluation provided on March 4, 2020, 
which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation provided on May 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies (A4595), alcohol wipes 
(A4245) and knee orthosis (L1851) provided on March 26, 2020. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did 
not include an itemized shipping/billing invoice or proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
documentation submitted did not include an itemized billing/shipping invoice or a proof of delivery for the 
billed date of service. To note, the delivery ticket includes a different date of service than what was billed. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for electrical stimulator supplies (A4595), alcohol 
wipes (A4245) and knee orthosis (L1851) provided on March 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on April 23, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that the member is in a nursing facility and does not have a 
choice of which lab service to use. The Plan denied your request. The Plan says prior authorization was not 
obtained by the facility. The Plan says that the member's primary care physician did not refer these services. 
 
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 
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 lab work provided on April 23, 2020 by an out of 
network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on February 21, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by the provider. The provider is a contract provider. The 
file does not show that the plan provided notice that the laboratory services would not be covered. Under 
Medicare rules, this means the laboratory services is considered approved by the plan. Therefore, we decided 
that the Plan has to pay for the laboratory services provided on February 21, 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 waive the copayment for the electrocardiographic recording services 
provided on March 3, 2020. 
 
You asked the Plan to waive the copayment for the electrocardiographic recording services. You say that you 
feel this service should be covered with no additional copayment. The Plan denied your request. The Plan says 
the services have been billed correctly per your plan benefits. 
 
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 $150 
copayment for each covered diagnostic procedure or test at a network outpatient facility.  
 
Your copayment requirement for each covered diagnostic procedure is $150. However, the allowed amount for 
this service is $132.09. Since this is less than your copayment requirement, you were charged the lesser 
amount. 
 
You have been asked to pay a $132.09 copayment for the electrocardiographic recording services. the 
electrocardiographic recording services fall within the outpatient diagnostic tests benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the electrocardiographic recording services provided on March 3, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by a 
participating provider on January 7, 2020 to January 28, 2020. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you didn't think that 
you would be charged a facility fee. The Plan denied your request. The Plan says the correct copayments have 
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 $325 
copayment for outpatient hospital services/3/non-surgical visit.  
 
You have been asked to pay a $129.47 which is less than your copayment amount of $325 for each outpatient 
hospital service. The total amount you are being asked to pay is $258.94 ($129.47 x 2 visits = $258.94). When 
you visit a provider, you may be charged an additional fee; therefore, the correct, copayments have been 
applied. Outpatient hospital services fall within the outpatient hospital services/3/non-surgical visit 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 outpatient hospital services provided by a 
participating provider on January 7, 2020 to January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the DME provided on May 29, 2020 by an out-of-network provider. 
 
You asked the Plan to pay for the DME. You say that the member was in a skilled nursing facility (SNF) since 
April 2020 and anything ordered was done by their doctors who you assumed received authorization. The Plan 
denied your request. The Plan says that there was no authorization on file for the services. 
 
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. You state the member was in a SNF and the DME was ordered by the 
physician's. The Plan did not provide any information verifying if the member was admitted to a network SNF. 
Therefore, we decided that the Plan has to pay for the DME provided on May 29, 2020 by an out-of-network 
provider.  
 
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation service 
(A0426) provided on February 29, 2020. 
 
You asked the Plan to waive the copayment 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 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 $260 
copayment for each covered, one-way ambulance trip by ground or water.  
 
You have been asked to pay a $260 copayment for the one-way covered ground ambulance trip 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 waive the copayment for the ambulance transportation service (A0426) provided on 
February 29, 2020.  
 
Your complaint about the condition of the ambulance that you were transported in 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 a fluoride varnish application (D1206) provided May 26, 
2020. 
 
You asked the Plan to pay for the fluoride varnish application. You say that the service should be covered. The 
Plan denied your request. The Plan says coverage for Flouride treatments is limited to treatments excluding 
Varnish. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 a fluoride 
varnish application (D1206) provided May 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 15, 2020. 
 
You asked the Plan to pay for the medical services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the procedure billed is an inpatient only 
procedure and is not payable under the OPPS per Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be ?inpatient-only? services. These services have an OPPS status indicator of ?C? in the 
OPPS Addendum B and are listed together in Addendum E of each year?s OPPS/ASC final rule.  
 
The service at issue in this appeal was billed with CPT code 60650. This code is listed with a status indicator of 
?C? on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as 
?inpatient only?, and therefore must be billed as part of an inpatient admission. Therefore, we decided that the 
Plan does not have to pay for the medical services provided on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown re-cementing (D2920) provided on June 3, 2020. 
 
You asked the Plan to pay for a crown re-cementing. You say that this was a minor procedure that probably 
cost less than a filling. The Plan denied your request. The Plan says this is 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 a crown 
re-cementing (D2920) provided on June 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for home health services provided on May 1, 2020 to May 11, 2020. 
 
You asked the Plan to waive the deductible for home health services. You say that you did not ask for these 
services. The Plan denied your request. The Plan says the correct deductible amount has been applied. 
 
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 there is a $750 deductible for home health agency care.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category home health 
agency care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible for home health agency care. This cost sharing is a contractual obligation that had not been met at 
the time home health services was received on May 1, 2020 to May 11, 2020. The total amount you are being 
asked to pay is $412.85. Therefore, we decided that the Plan does not have to waive the deductible for home 
health services provided on May 1, 2020 to May 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on January 
23, 2020. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received laboratory services on the date of service at issue in this appeal. The 
Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 Outpatient diagnostic tests.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received laboratory 
services on January 23, 2020. You have been asked to pay a $35 copayment for the laboratory services. The 
laboratory services fall within the Outpatient diagnostic tests benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the laboratory services provided on January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye examination provided on March 6, 
2020. 
 
You asked the Plan to waive the copayment for eye exam. You say that this was a routine eye examination. The 
Plan denied your request. The Plan says the copayment 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $40 
copayment for diagnostic eye exam. This exam was provided for a non-routine diagnosis, so it is considered to 
be a diagnostic eye exam with applicable copayment. 
 
You have been asked to pay $40 copayment for eye exam. Eye exam falls within the Vision 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 eye examination provided on March 6, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiac monitoring testing provided on 
May 1, 2020. 
 
You asked the Plan to waive the copayment for cardiac monitoring testing. You say that you believe you 
canceled this appointment. The Plan denied your request. The Plan says the copayment you are being charged 
is correct. 
 
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 
copayment for per visit for laboratory tests, non-radiological diagnostic tests, flat film X-rays, and ultrasounds.  
 
You have been asked to pay a $20 copayment for cardiac monitoring testing. Cardiac monitoring testing 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 copayment for cardiac monitoring testing provided on May 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for EpiFix tissue replacement supplies and a 
specialist visit you received on May 28, 2020. 
 
You asked the Plan to waive the cost sharing for the tissue replacement supplies and specialist visit. You say 
that you had this service before and were not charged anything, so you weren't expecting cost sharing to apply. 
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 20% 
coinsurance for prosthetic devices and related supplies. Your contract also says that you must pa a $20 
copayment for specialist visits. 
 
You have been asked to pay 20% coinsurance for the tissue replacement supplies and a $20 copayment for the 
specialist visit. The tissue replacement supplies fall within the prosthetic devices and related supplies benefit 
category. In addition, your Evidence of Coverage states that you pay $20 for specialist visits. 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 cost sharing for EpiFix tissue replacement supplies and a specialist visit you 
received on May 28, 2020.