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

 
We decided that the Plan does not have to waive the copayment for the dialysis circuit procedure (36902) 
provided February 13, 2020. 
 
You asked the Plan to waive the copayment for the dialysis circuit procedure. You say that when you started 
dialysis you were told you would never see a dialysis related bill. You believe this is dialysis related as they 
changed the site on your arm so it would bump faster. The Plan denied your request. The Plan says this correct 
copayment was applied as the procedure took place in an outpatient department of a hospital. 
 
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 $150 
copayment for each Medicare covered outpatient hospital service, including observation outpatient surgery or 
procedure. for outpatient hospital services.  
 
You have been asked to pay $150 copayment for each Medicare covered outpatient hospital service, including 
observation outpatient surgery or procedure. for the dialysis circuit procedure. the dialysis circuit procedure 
falls within the outpatient hospital 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 the dialysis circuit procedure (36902) provided February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided. 
 
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 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 nurse practitioner services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the diabetic shoe inserts rendered on July 
9, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the coinsurance was 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 20% 
coinsurance for durable medical equipment and supplies.  
 
Review of the file shows that you received diabetic shoe inserts on July 9, 2020. You have been asked to pay a 
20% coinsurance for these services. These services fall within the durable medical equipment 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 coinsurance for the diabetic shoe inserts 
rendered on July 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
November 11, 2019. 
 
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 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 physician 
services provided to the enrollee on November 11, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87641, 87798, and 87900) and the 
travel allowance (P9603) provided on November 25, 2019. 
 
You asked the Plan to pay for the laboratory services and the travel allowance. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physician's intent that the test be performed prior to services taking place. 
 
Medicare rules also say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. CPT code P9603 has a status code of "X" under the MPFSDB and represents a service 
that is not in the statutory definition of "physician services" for fee schedule payment purposes. 
 
Therefore, we decided that the Plan does not have to pay for the laboratory services (87641, 87798, and 87900) 
and the travel allowance (P9603) provided on November 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
rendered on May 4, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that someone should have let you know 
that there would be a copayment. The Plan denied your request. The Plan says the copayment was 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 $100 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a 
physician's office or at a freestanding facility.  
 
Review of the file shows that you received a CT scan on May 4, 2020. You have been asked to pay a $100 
copayment for these services. These services fall within the Medicare-covered radiological diagnostic service, 
not including x-rays, performed in a physician's office or at a freestanding facility 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 computed tomography (CT) scan rendered on May 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a soft cervical collar (L0172) received on 
June 3, 2020. 
 
You asked the Plan to waive the coinsurance for a soft cervical collar. You say that you don't recall the enrollee 
receiving a cervical collar. The Plan denied your request. The Plan says the correct coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for durable medical equipment (DME) and related supplies.  
 
The enrollee has been asked to pay $16.50, or 20% coinsurance of the Plan-allowed amount of $82.51, for a 
soft cervical collar. A soft cervical collar falls within the "Durable medical equipment (DME) and related 
supplies" benefit category. This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a soft cervical collar 
(L0172) received on June 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal maintenance (D4910) provided on 
January 15, 2020. 
 
You asked the Plan to pay more for the dental service. You say that you declined periodontal maintenance 
before any services were provided on the date of service. You say that you had a routine cleaning done. You 
also say that you did not consent or have knowledge that you were going to receive periodontal maintenance. 
The Plan denied your request. The Plan says periodontal maintenance was completed and not a routine 
prophylaxis on the date of service. The Plan also says that the claim processed correctly. 
 
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 and periodontal maintenance is a 
covered service, the there is a 70% cost share amount that is applicable. Additionally, the record shows that 
periodontal maintenance was performed on the date of service and the claim processed correctly. Therefore, we 
decided that the Plan does not have to pay more for the periodontal maintenance (D4910) provided on January 
15, 2020.  
 
Your complaint about the provider's professionalism 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG). 
 
You asked the Plan to waive the copayment for these services. You say that you were told that all services were 
covered. The Plan denied your request. The Plan says the copayment was 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 $30 
copayment for Medicare-covered non-radiological diagnostic services.  
 
Review of the file shows that you received an EKG. Per the contract with the Plan, there is a 
$30 copayment for Medicare-covered non-radiological diagnostic services. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these 
services was $17.59. Given that the allowed amount was less than the $30 copayment, you have been asked to 
pay $17.59 for these services. 
 
Therefore, we decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided. 
 
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 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 physician services provided to the enrollee on 
March 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on April 24, 2020.
You asked the Plan to waive the copayment for these services. You say that you would like to know why the services are not covered. The Plan denied your request. The Plan says the copayment was 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 $295 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center or outpatient hospital facility.
Review of the file shows that you received outpatient surgical services in the form of catheter removal on April 24, 2020. Per the contract with the Plan, there is a $295 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center or outpatient hospital facility. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $82.17. Given that the allowed amount was less than the $295 copayment, you have been asked to pay $82.17 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on April 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the adjacent tissue transfer (14041) 
provided march 16, 2020. 
 
You asked the Plan to waive the copayment for the adjacent tissue transfer. You say that you do not feel that 
you should have to pay $255. You feel that the copayment should be $45. The Plan denied your request. The 
Plan says this claim processed and the correct copayment was applied per the Evidence of Coverage. 
 
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 $225 
copay for each covered surgery in an ambulatory surgical center for outpatient surgery, including services 
provided at hospital outpatient facilities and ambulatory surgical centers.  
 
You have been asked to pay $225 copay for each covered surgery in an ambulatory surgical center for the 
adjacent tissue transfer. the adjacent tissue transfer falls within the outpatient surgery, including services 
provided at hospital outpatient facilities and ambulatory surgical centers 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 adjacent tissue transfer (14041) provided march 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic treatment provided from May 27, 2020, through 
June 1, 2020. 
 
You asked the Plan to pay for the chiropractic treatment. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
chiropractic treatment. 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 chiropractic treatment provided from May 27, 2020, through 
June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of an erupted tooth or exposed root and 
extraction of an erupted tooth requiring removal of bone and/or sectioning of tooth provided on January 13, 
2020 by an OON provider. 
 
You asked the Plan to pay for the extractions. You say that you found this provider on the Plan's website, 
which shows that this provider was an in-network provider with your plan. The Plan denied your request. The 
Plan says the treating provider is not a participating provider with your dental plan. The Plan also says that 
services provided by an OON dentist 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, you are responsible for the full cost for 
services that are rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for 
the extraction of an erupted tooth or exposed root and extraction of an erupted tooth requiring removal of bone 
and/or sectioning of tooth provided on January 13, 2020 by an OON provider.
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 these services were 
medically necessary and you would like this copayment waived. 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 $50 
copayment for emergency care.  
 
You have been asked to pay a $50 copayment for an emergency room visit. When observation services are 
provided overnight, the emergency room copayment is not waived; therefore, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the services provided on March 23, 2020. 
 
You asked the Plan to waive the copayment for the services. You say that due to COVID your appointment was 
cancelled and you had a call with the CNP to go over medications before the refills were done. The Plan denied 
your request. The Plan says the claim was processed accordingly with your 2020 EOC 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).  
 
Review of the file show that you received a telehealth call with the physician's office on March 23, 2020. The 
Medicare-allowed amount for the specialist services is less than the set $40 copayment; therefore, you have 
been asked to pay the lesser amount of $36 for the 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 the services provided on March 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a paring/cutting of lesion (11055), a nail 
debridement (11721), and a nail plate removal (11730) performed on July 11, 2020. 
 
You asked the Plan to waive the deductible for a paring/cutting of lesion, a nail debridement, and a nail plate 
removal. You say that the provider is inaccurately billing you and the Plan. The Plan denied your request. The 
Plan says the correct cost-sharing was 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 Medicare-covered podiatry visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category "Podiatry 
services." The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible for Medicare-covered podiatry visits. This cost sharing is a contractual obligation that had not been 
met at the time a paring/cutting of lesion, a nail debridement, and a nail plate removal was received on July 11, 
2020. Therefore, we decided that the Plan does not have to waive the deductible for a paring/cutting of lesion 
(11055), a nail debridement (11721), and a nail plate removal (11730) performed on July 11, 2020.  
 
Your complaint about being inaccurately billed by the provider 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the physician services provided on October 
1, 2019. 
 
You asked the Plan to waive the cost share for the physician 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 physician services on the date of service at issue in this appeal. The 
Plan says that the correct cost share 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. Your 
contract with the Plan says that there is a $500 deductible that must be met before the Plan will pay their share 
for Physician/Practitioner services.  
 
The item or service you asked the Plan to waive the cost share for falls within the benefit category 
Physician/Practitioner services. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $500 deductible that must be met before the Plan will pay their share for out-of-network 
Physician/Practitioner services. This cost sharing is a contractual obligation that had not been met at the time 
the physician services were received on October 1, 2019. Therefore, we decided that the Plan does not have to 
waive the cost share for the physician services provided on October 1, 2019.