Persius/hicric huggingface dataset:
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. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you feel like nothing 
was done this visit and you should not have to pay for this. The Plan denied your request. The Plan says the 
correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for emergency care.  
 
You have been asked to pay a $120 copayment for an emergency room visit. Since an emergency room visit 
was provided, the correct copayment has been applied. 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.  
 
We note your complaint about feeling like nothing was done on the first emergency room visit.  Your complaint 
is a grievance that must be answered by the health 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 filling (D2330) for tooth # 6 provided on July 17, 2020. 
 
You asked the Plan to pay for the dental service. You say that this should be covered by your dental plan. The 
Plan denied your request. The Plan says the filling is not listed as a covered service. 
 
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 filling 
(D2330) for tooth # 6 provided on July 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 1, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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. 
 
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 June 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device (CPT Code 
22869). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says the device is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pre-approve the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex Superion Interspinous device (CPT Code 22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment and other services 
performed by a chiropractor on June 15, 2020. 
 
You asked the Plan to pay for chiropractic services. You say that the Plan has covered these services in the 
past. The Plan denied your request. The Plan says the copayment amount you are being charged is correct. The 
Plan also says that the denial of payment for the office visit and electrical stimulation therapy charges is 
correct, because these services are not covered when performed by a chiropractor. 
 
The Plan must follow Medicare rules. 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 copayment for each covered chiropractic visit. The rules say that the only 
chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.  
 
You have been asked to pay $20 copayment for the covered chiropractic manipulative treatment. Chiropractic 
manipulative treatment falls within the Chiropractic Services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. Additionally, the office visit and 
electrical stimulation therapy services are not manual manipulation of the spine, and are therefore not covered 
by Medicare or the Plan when performed by a chiropractor. Therefore, we decided that the Plan does not have 
to pay for chiropractic manipulative treatment and other services performed by a chiropractor on June 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lab services you received on May 19, 
2020, and August 19, 2020. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible 
for the cost share. 
 
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 Medicare-covered lab services and diagnostic procedures/tests performed in an outpatient 
hospital facility.  
 
Review of the file shows that you were provided lab services on May 19, 2020, and August 19, 2020. Per your 
contract with the Plan, there is a $30 copayment for lab services provided at an outpatient hospital facility. 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 lab services you received on May 19, 2020, and August 
19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collection of venous blood by venipuncture (36415) 
provided on June 1, 2020. 
 
You asked the Plan to pay for the collection of venous blood by venipuncture. You say that you would like 
reconsideration because network status does not apply to charges billed by an Indian tribe or tribal 
organization. The Plan denied your request. The Plan says this claim was reimbursed based on Medicare rules 
for Indian Health Services. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the collection of venous blood by venipuncture have not been met. Specifically, this claim was  not 
submitted with revenue code 01510. Therefore, we decided that the Plan does not have to pay for the collection 
of venous blood by venipuncture (36415) provided on June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nitrous oxide (D9230), the unspecified preventive 
procedure (D1999), and the 7 extractions (D7140) provided on May 29, 2020. 
 
You asked the Plan to pay for the dental services. You say that you need to have your teeth extracted before 
you can have your knee replacement surgery. You say that your original dentist was closed due to Covid-19 
and does not do extractions. You say that you only have 3 teeth left on the bottom left and cannot eat. The Plan 
denied your request. The Plan says the provider in this case is not a network provider. The Plan also says that 
dental services that you receive out of network are 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, dental services that you receive out of 
network are not covered. Therefore, we decided that the Plan does not have to pay for the nitrous oxide 
(D9230), the unspecified preventive procedure (D1999), and the 7 extractions (D7140) provided on May 29, 
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel SureClick. 
 
You asked the Plan to pre-approve Enbrel SureClick. The Plan denied your request. The Plan says Enbrel 
SureClick is not covered under the medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Enbrel SureClick.  
 
Benefits for Enbrel SureClick may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on May 12, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on May 12, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit provided to the enrollee on May 2, 
2020. 
 
You asked the Plan to pay for the services. You say that an Indian tribe or tribal organization has the right to 
recover from an insurance company. The Plan denied your request. The Plan says the claim was not billed in 
accordance with CMS guidelines, and a corrected claim has not been submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the denied codes were not supported in the medical record. Specifically, these services should be 
billed with a revenue code of 0510, and a type of bill of 13X. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for an emergency room visit provided to the enrollee on May 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on June 18, 
2020. 
 
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 the enrollee did not have prior authorization for out of network care. 
 
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 out of network services provided to the enrollee on 
June 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 19, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 19, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 19, 
2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says there are no skilled nursing or therapy needs. 
 
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 pre-approve the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan does not have to pay for the oral exam (D0120) provided on June 23, 2020. 
 
You asked the Plan to pay for the oral exam. You say that you were never told that you would have to pay for 
the exam. You say that the plan should just cover 1 exam and cleaning instead of half of 2. You also say that 
you should not have to pay for something because you only pay for half. The Plan denied your request. The 
Plan says 1 oral exam is covered every year. The Plan says that the frequency limit of oral exams has been 
exceeded. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms the specific terms in which a service 
is covered. Your contract with the Plan does not say in clear and accurate terms how a year is measured.  
 
We looked at your contract with the Plan. We did not see where the contract specifically states that oral exams 
are covered once in a 12-month period. The record shows that the last oral exam that you received was on 
December 19, 2019. It is reasonable that the enrollee did not think they would have to pay for an oral exam in 
2020 because the last one they received was in the previous calendar year. This means that the Plan did not 
follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan does not 
have to pay for the oral exam (D0120) provided on June 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
head or brain (70450) provided on July 23, 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 $225 
copayment for each Medicare-covered advanced imaging service.  
 
You have been asked to pay a $225 copayment for the advanced imaging service 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 computed tomography (CT) scan of the head or brain (70450) 
provided on July 23, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room visit provided June 2, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should 
be waived. 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 $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for the emergency room visit. The 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 June 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis provided from February 5, 
2020, to February 19, 2020. 
 
You asked the Plan to waive the copayment for arthrocentesis. You say that you were not informed that you 
would owe a copayment. 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 $45 
copayment for specialist services.  
 
You received arthrocentesis from February 5, 2020, to February 19, 2020 for a total of 3 visits. Therefore, you 
are responsible to pay a $45 copayment per each visit. The total amount you owe is: $45 (copayment) x 3 
(specialist visits) = $135.  
 
You have been asked to pay the total copayment amount of $135 for arthrocentesis. Arthrocentesis falls within 
the physician/practitioner services, including doctors office visits 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 arthrocentesis provided from February 5, 2020, to February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided. 
 
You asked the Plan to waive the copayment for the office visit. You say that you paid $35 and now you owe an 
additional charge. You say that the doctor is in-network and you want assistance sorting out the bills. 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 provider and professional services at an in-network specialist's office.  
 
You have been asked to pay a $35 copayment for the office visit. The office visit falls within the 
"Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has confirmed that 
you paid your $35 copayment and there are no additional charges. This means that you were 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 office visit provided.