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

 
We decided that the Plan does not have to waive the copayment for MRI's on March 2, 2020. 
 
You asked the Plan to waive the copayment for MRI's. You say that you disagree with the charges because you 
were told that you would only owe one $85 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 an $85 
copayment for each MRI. 
 
You received three MRI's on March 2, 2020. Therefore, you are responsible to pay an $85 copayment per each 
MRI. The total amount you owe is: $255. 
 
You have been asked to pay the total copayment amount of $255 for MRI's. MRI's fall 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 MRI's on March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent urinary catheters (A4351) provided on April 15, 
2019. 
 
You asked the Plan to pay for the intermittent urinary catheters. You say that you would like reconsideration 
because these supplies are medically necessary. The Plan denied your request. The Plan says the documentation 
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. 
 
We find that CPT code A4351 is not supported in the medical record. Specifically, the physician order 
indicates that 200 units are to be supplied per month. The record shows that 600 units were delivered for this 
date of service. There is no indication in the record to suggest that more than one month of supplies has been 
billed. Based on this information, we decided that Medicare rules for coverage of the intermittent urinary 
catheters have not been met. Therefore, we decided that the Plan does not have to pay for intermittent urinary 
catheters (A4351) provided on April 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays and prophylaxis 
provided on June 3, 2020 by an OON provider. 
 
You asked the Plan to pay for the complete series of intraoral x-rays and prophylaxis. You say that it is your 
understanding that the Plan will pay for one set of x-rays and one cleaning annually. You also say that the data 
online says that you may be reimbursed 50%. The Plan denied your request. The Plan says the complete series 
of intraoral x-rays is not a covered benefit. The Plan also says that these services were received by a non-
participating provider, and you are responsible for any difference between the Maximum Allowable Fee and 
the amount the provider bills you for the services. 
 
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, complete series of intraoral x-rays is 
not among those covered under this benefit. You are also responsible for any amount greater than the payment 
made by the Plan to the provider for covered services that are received OON. Therefore, we decided that the 
Plan does not have to pay for the complete series of intraoral x-rays and prophylaxis provided on June 3, 2020 
by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on June 19, 2020. 
 
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says you must obtain 
hearing aids from the Plan's hearing aid provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for 
hearing aids only when provided by the Plan?s hearing aid provider. 
 
We looked at the file and the Plan's rules. The file shows that you purchased the hearing aids from a provider 
that is not a Plan provider. Based on this information, we decided that the Plan's rules for coverage of the 
hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids 
provided on June 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for a specialist office visit (99214), an ultrasound heart exam (93306), an ultrasound of extracranial blood flow (93880), a pacemaker device evaluation (93288), a nuclear medicine study (78452), and a dose of a diagnostic aid (A9502), performed on April 6, 2020.

You asked the Plan to waive the cost-sharing for a specialist office visit, 3 diagnostic procedures, a pacemaker device evaluation, and a dose of a diagnostic aid. You say that there was not a stacking of separate copayments in previous years. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for each Medicare-covered radiological diagnostic service, not including X-rays; a $20 copayment for Medicare-covered non-radiological diagnostic services; 20% coinsurance for each Medicare-covered medical supply; and a $45 copayment for consultation, diagnosis, and treatment by a specialist. 

You have been asked to pay $559.44. This is the sum of: a $150 copayment for each of 3 diagnostic procedures ($150 x 3 = $450), a $20 copayment for a pacemaker device evaluation, a $45 copayment for a specialist office visit, and $44.44 coinsurance, or 20% of the Plan-allowed amount of $222.20, for a dose of a diagnostic aid. Three diagnostic procedures, a pacemaker device evaluation, and a dose of a diagnostic aid fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. A specialist office visit falls within the "Physician/Practitioner Services, Including Doctor's 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 cost-sharing for a specialist office visit (99214), an ultrasound heart exam (93306), an ultrasound of extracranial blood flow (93880), a pacemaker device evaluation (93288), a nuclear medicine study (78452), and a dose of a diagnostic aid (A9502), performed on April 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) rendered by the out of network 
(OON) provider on February 20, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the office visit (99213) rendered by the out of network (OON) provider on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on June 16, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that it is the facility's responsibility to obtain 
prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the 
skilled nursing facility or provider. The Plan says that the referring provider is also out-of-network. 
 
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 skilled nursing services provided on June 16, 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 a domiciliary or rest home visit provided on February 18, 
2020. 
 
You asked the Plan to pay for the domiciliary or rest home visit. 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 a domiciliary or rest home visit provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90832) rendered by the out of network 
(OON) provider on March 9, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the psychotherapy (90832) rendered by the out of network (OON) provider on March 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional intraoral 
periapical x-ray, bitewings, comprehensive oral evaluation, prophylaxis, two preventive procedures, and resin-
based composite provided on June 1, 2020 and June 15, 2020 by an OON provider. 
 
You asked the Plan to pay for the dental services. You say that you contacted the provider's office and 
confirmed that they accepted your insurance.  The Plan denied your request. The Plan says the treating provider 
is not an in-network provider with your dental plan. The Plan also says that provider's office confirmed that you 
did not mention that you had a Dual Medicare Plan, and would have been told that the treating provider was not 
in-network if you had. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the first 
intraoral periapical x-ray, additional intraoral periapical x-ray, bitewings, comprehensive oral evaluation, 
prophylaxis, two preventive procedures, and resin-based composite provided on June 1, 2020 and June 15, 
2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown replacement for tooth #5 provided on May 19, 
2020. 
 
You asked the Plan to pay for the crown replacement for tooth #5. You say that you couldn't live with a 
crumbled tooth for two years. You say that you had no alternative but to replace the crown. The Plan denied 
your request. The Plan says the replacement exceeds the frequency limitation of the elected 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, the Plan also has a maximum benefit 
of one crown replacement every 7 years. The records show that the crown was originally placed on September 
2, 2015 and replaced on May 19, 2020. Therefore, we decided that the Plan does not have to pay for the crown 
replacement for tooth #5 provided on May 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the skin lesion removal you had at your 
dermatologist's office on June 23, 2020. 
 
You asked the Plan to waive the deductible for the skin lesion removal. You say that you should only owe a 
$35 copayment for this service.  The Plan denied your request. The Plan says you were charged this deductible 
correctly. 
 
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.  This deductible applies to specialist services beyond 
a regular office visit.  
 
In this case, you received skin lesion removal in addition to your specialist office visit. This skin lesion 
removal is a surgical service for which the deductible will apply. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $750 deductible for surgical services provided in an specialist's 
office. This cost sharing is a contractual obligation that had not been met at the time the skin lesion removal 
was received on June 23, 2020. Therefore, we decided that the Plan does not have to waive the deductible for 
the skin lesion removal you had at your dermatologist's office on June 23, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had on 
May 29, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this test was ordered 
due to a false-positive result from a Cologuard test. 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 $250 
copayment for outpatient surgery.  
 
You have been asked to pay a $250 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy 
you falls within the outpatient surgery benefit category because your doctor ordered a diagnostic colonoscopy 
for you, not a screening colonoscopy. This test was ordered for you because of a positive Cologuard test.  In 
other words, it was requested due to signs or symptoms of potential disease.  It was ordered as a diagnostic 
procedure and it was billed as a diagnostic procedure. 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 diagnostic colonoscopy you had on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the percutaneous arterial transluminal mechanical 
thrombectomy provided on April 25, 2020. 
 
You asked the Plan to pay for Percutaneous arterial transluminal mechanical thrombectomy and/or infusion for 
thrombolysis (66145). You say that this claim should be paid. The Plan denied your request. The Plan says this 
claim cannot be paid separately based on Medicare guidelines for inpatient services. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary during an inpatient stay. The facility or 
hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements 
made with outside providers.  
 
This was an inpatient service. Payment for this service would have been included under the global facility 
claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that 
the Plan does not have to pay for the percutaneous arterial transluminal mechanical thrombectomy provided on 
April 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 8, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the home visit (99336). You say that you would like reconsideration because the 
services rendered were medically necessary. The Plan denied your request. The Plan says the member's care 
was not urgent enough to require in area 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 the medical services provided on January 8, 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 Prometheus Anser VDZ testing provided on January 14, 
2020. 
 
You asked the Plan to pay for the Prometheus Anser VDZ testing. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered 
benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The Prometheus Anser VDZ testing at issue in this appeal was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the Prometheus Anser VDZ testing provided on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) provided on March 18, 
2020. 
 
You asked the Plan to pay for the oral hygiene instructions. The Plan denied your request. The Plan says this 
service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral 
hygiene instructions (D1330) provided on March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on February 27, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and 
approved for payment. you say that it is the facility's responsibility to obtained prior authorization. The Plan 
denied your request. The Plan says prior authorization was not obtained by the facility or the provider. The 
Plan says that because there was no prior authorization for these services, 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 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 skilled nursing services provided on February 27, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) on June 16, 
2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that this service should have a 
$5 copayment. 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 $35 
copayment for each specialist visit.  
 
You have been asked to pay a $35 copayment for a specialist office visit. The provider you saw on June 16, 
2020, is not a general practitioner but a specialist practitioner. A specialist office visit falls within the 
"Physician/Practitioner services, including doctor?s 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 a specialist office visit (99213) on June 16, 2020.