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

We decided that the Plan does not have to waive the cost sharing for testing services and office visits from February 7, 2020 to March 2, 2020.
You asked the Plan to waive the cost sharing for testing services and office visits. You say that you were told that your doctor was in network. The Plan denied your request. The Plan says the cost share 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 30% coinsurance for out of network Medicare-covered diagnostic procedures and tests, lab services, blood services, diagnostic and nuclear medicine radiological services, therapeutic radiology services and X-rays. Your contract with the Plan also clearly says that you must pay a $40 copayment for each out of network Medicare-covered primary care doctor visit. You have been asked to pay a $4.02 coinsurance for testing services received on February 7, 2020, which is 30% of the allowed amount of $13.39. Testing services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. You have been asked to pay two $40 copayments for two office visits on February 10, 2020 and March 2, 2020. Office visits fall 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 testing services and office visits from February 7, 2020 to March 2, 2020.
Your complaint about being told by an agent that this doctor was in network 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive and definitive drug testing and assays for 
other drugs provided on December 17, 2019. 
 
You asked the Plan to pay for the lab testing. You say that this testing is medically necessary and should be 
covered. The Plan denied your request. The Plan says the order does not specify the drug to be tested. There is 
also no evidence that a blood sample was submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the 
treating provider. The rules also say that providers must use the correct code for services rendered. 
 
The order form does not clearly document the testing to be provided and, as such, the codes 80307 and G0483 
are not supported. The remainder of the billed codes are for testing on a plasma sample. Since there is no 
evidence that a plasma sample was submitted to the lab, these codes are also not supported. Therefore, we 
decided that the Plan does not have to pay for the presumptive and definitive drug testing and assays for other 
drugs provided on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient telemedicine specialist visit 
provided on April 30, 2020. 
 
You asked the Plan to waive the copayment for a telemedicine specialist visit. You say that you did not agree to 
the service. 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 $40 
copayment for per visit to a specialist under the Preferred Rx plan.  
 
You have been asked to pay a $40 copayment for a telemedicine specialist visit. A telemedicine specialist 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 an outpatient telemedicine specialist visit provided on April 30, 
2020.  
 
Your complaint about not agreeing to the service 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 outpatient hospital observation services 
provided from February 20, 2020 to February 21, 2020. 
 
You asked the Plan to waive the copayment for observation services. You say that you did not leave the 
emergency room and paid an ER copay. 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 $200 
copayment for each Medicare-covered outpatient hospital facility visit, clinic, outpatient treatment room, 
observation room, or outpatient surgery services.  
 
You have been asked to pay a $200 copayment for observation services. Observation services falls within the 
Outpatient Hospital Observation 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 observation services provided from February 20, 2020 to February 21, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to grant your request as the cost share is already at the in-network rate.  
 
You asked the Plan to pay for out of network inpatient care at the in-network rate. You say that you cannot 
afford this bill and would like it covered at the in-network rate. The Plan denied your request. The Plan says the 
cost share applied is at the in-network rate, per your Plan contract agreement. 
 
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 $210 per 
day for days 1 to 6 of an inpatient stay ($1260) and $90 for emergency rooms visits. For this inpatient stay both 
in and out of network it would be $1350. 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 grant your request as you are already being charged 
the in-network rate.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for compounded drugs (J7999 x 45, J7999 x 42, J7999 x 15) 
provided December 11, 2019. 
 
You asked the Plan to pay for compounded drugs. You say that the records indicate a compound drug was 
administered. The Plan denied your request. The Plan says the billed services cannot be verified. 
 
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 J7999 is not supported in the medical record. Specifically, the number of units billed 
could not be verified in the medical records. Based on this information, we decided that Medicare rules for 
coverage of compounded drugs have not been met. Therefore, we decided that the Plan does not have to pay for 
compounded drugs (J7999 x 45, J7999 x 42, J7999 x 15) provided December 11, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 28, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Medicare rules say that providers must produce medical records showing why the lab services provided were 
medically necessary. We find that CPT codes 80307 and G0483 are not supported in the medical record. In this 
case, there were insufficient medical records to show the testing was individualized to identify specific non-
prescribed medications or illicit substances. The records provided do not document concerns based on clinical 
review and judgement. 
 
We find that CPT codes 80157, 80159, 80162, 80173, 80177, and 80201 are not supported in the medical 
record. This testing at issue is performed on a blood sample. The records do not indicate a blood sample was 
obtained from the enrollee. 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 on January 28, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room Visit and Inpatient Care provided September 1, 2019 to September 6, 2019.
You asked the Plan to waive the copayment for the Emergency Room Visit and Inpatient Care. You say that the quality of service was poor so the copayments should be waived. The Plan denied your request. The Plan says the correct copayments were applied for the services rendered.
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 Room Visits and a $300 per day copayment for inpatient care. You have been asked to pay a $90 copayment for the Emergency Room Visit and a $1500 copayment for 5 days of inpatient care ($300 per day). 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 and Inpatient Care provided September 1, 2019 to September 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a TDAP vaccine given to the enrollee on February 3, 2020. 
 
You asked the Plan to pay for this vaccine. You say that this claim should be paid. The Plan denied your 
request. The Plan says this vaccine is not covered under Medicare Part B and should be billed to the enrollee's 
Medicare Part D carrier. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide this vaccine. The 
Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness 
related to this vaccine. Therefore, we decided that the Plan does not have to pay for a TDAP vaccine given to 
the enrollee on February 3, 2020.  
 
Benefits for this vaccine 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the spine (72100) provided January 27, 2020. 
 
You asked the Plan to pay for the x-ray. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the claim was submitted with an incorrect place of service. 
 
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 72100 is not supported in the medical record. Specifically, the claim shows an 
outpatient place of service, but the enrollee was an inpatient on the dates of service at issue. Based on this 
information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we 
decided that the Plan does not have to pay for an x-ray of the spine (72100) provided January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an office visit (99213) and retina scan 
(92134) provided March 10, 2020. 
 
You asked the Plan to waive the copayments for the office visit and retina scan. You say that the copayments 
should be waived. The Plan denied your request. The Plan says the correct copayments were 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 specialist visits and a $15 copayment for diagnostic tests.  
 
You have been asked to pay a $35 copayment for a specialist visit and a $15 copayment for a retina scan which 
is considered a diagnostic test. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayments for an office visit (99213) and 
retina scan (92134) provided March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 10, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan contract 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. These services are not urgent or emergent, nor were they approved in advance.
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 laboratory 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 laboratory services provided on February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided February 3, 2020 to February 27, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that these tests were ordered by a physician. The Plan denied 
your request. The Plan says prior authorization was not obtained. 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 February 3, 2020 to 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 or reduce the copayments for specialist services and radiation 
therapy provided from January 3, 2020 to February 26, 2020. 
 
You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct. 
The Plan denied your request. The Plan says this cost share was charged based on the services provided and the 
Plan contract agreement. The Plan also notes your provider was made aware of this cost share prior to services 
being rendered.  
 
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 $25 
copayment for each specialist visit and 20% coinsurance for each radiation therapy visit.  
 
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 or reduce the copayments for specialist services and radiation therapy provided from 
January 3, 2020 to February 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on January 14, 2020. 
 
You asked the Plan to pay for the bitewing x-rays (D0274). You say that you thought one x-ray a year was 
covered. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
bitewing x-rays (D0274) provided on January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on December 17, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that these labs were referred to you by a provider. The Plan 
denied your request. The Plan says prior authorization was not obtained. 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 December 17, 2019 by an 
out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided October 1, 2019 to 
October 2, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically 
necessary. The Plan denied your request. The Plan says the enrollee's condition could be managed in the 
observation setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency and/or 
observation care) would span two midnights. 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided October 1, 2019 to October 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Face Down Recovery Equipment rented on 
February 24, 2020. 
 
You asked the Plan to reimburse you for the vitrectomy recovery equipment. You say that the vitrectomy 
recovery equipment was medically necessary and you were told it would be covered. The Plan denied your 
request. The Plan says vitrectomy recovery equipment is statutorily not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare will not pay for precautionary equipment. 
 
This item is precautionary and not covered by Medicare. Therefore, we decided that the Plan does not have to 
reimburse you for the Face Down Recovery Equipment rented on February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for localized delivery of antimicrobial agents (D4381), gingival 
irrigation (D4921) and drugs or medicaments (D9630) provided on February 25, 2020. 
 
You asked the Plan to pay for the localized delivery of antimicrobial agents (D4381), gingival irrigation 
(D4921) and drugs or medicaments (D9630). You say that periodontics is included in your 2020 Evidence of 
Coverage. The Plan denied your request. The Plan says the services are not covered 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for localized 
delivery of antimicrobial agents (D4381), gingival irrigation (D4921) and drugs or medicaments (D9630) 
provided on February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction provided on March 13, 2020. 
 
You asked the Plan to pay for the eye refraction. You say that you believed the appointment was covered after 
your copay. The Plan denied your request. The Plan says refractive services are not covered unless performed 
by a routine vision care provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. The file shows that you received eye refraction services during a 
diagnostic eye exam, provided by an out-of-network provider. Your plan only covers refraction during routine 
exams when provided by a routine vision care provider. Based on this information, we decided that the Plan's 
rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to 
pay for the eye refraction provided on March 13, 2020.