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

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on 
May 12, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you were under the impression that 
the services would be entirely covered once approved. 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 $250 
copayment for each Medicare-covered outpatient hospital facility visit, clinic, outpatient treatment room, 
observation room, or outpatient surgery services.  
 
Review of the file shows that you received outpatient hospital services on May 12, 2020. Per the contract with 
the Plan, there is a $250 copayment for each Medicare-covered outpatient hospital facility visit, clinic, 
outpatient treatment room, observation room, or outpatient surgery 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 $112.35. Given that the allowed amount was less than the $250 copayment, you have been asked 
to pay $112.35 for these services. Therefore, we decided that the Plan does not have to waive the copayment 
for the outpatient hospital services rendered on May 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 5, 2020, and May 26, 
2020. 
 
You asked the Plan to pay for dental services. You say that the in-network provider tried to fix it twice with no 
success. You say that this was an emergency with broken screws in your mouth. The Plan denied your request. 
The Plan says out-of-network dental 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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
services provided on March 5, 2020, and May 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing rendered on September 16, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says screening tests are not covered. 
 
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 test at issue in this appeal, these services, 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 
genetic testing rendered on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services rendered on January 
6, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99358 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99358 is prolonged evaluation and management service 
before and/or after direct patient care; first hour. 
 
We find that CPT code 99358 is not supported in the medical record. Specifically, there is no documentation of 
the first hour of prolonged evaluation and management services spent on the enrollee. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the evaluation and management services rendered on January 6, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services (74018) provided on May 1, 2020. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not emergent or pre-authorized. There were network 
providers available. 
 
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 service 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 radiology services (74018) provided on May 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on October 30, 2019. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you cannot afford this 
copayment. 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 $250 
copayment for outpatient surgery/ambulatory surgical center.  
 
You have been asked to pay a $250 copayment for cataract surgery. Cataract surgery falls within the outpatient 
surgery/ambulatory surgical center 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 surgery provided by a participating provider on October 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of a refractive state (92015) provided on 
May 13, 2020. 
 
You asked the Plan to pay for the determination of a refractive state. You say that you would like 
reconsideration because this provider was checking for glaucoma, macular degeneration, retinal problems and 
infections. The Plan denied your request. The Plan says you do not have routine vision coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services. Medicare does not cover eye 
refraction. Therefore, we decided that the Plan does not have to pay for the determination of a refractive state 
(92015) provided on May 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit and coinsurance for 
ultrasounds provided by a participating provider on December 2, 2019. 
 
You asked the Plan to waive the copayment for a specialist office visit and coinsurance for ultrasounds. You 
say that you were told that there wouldn't be any additional fees. The Plan denied your request. The Plan says 
the correct copayment and coinsurance have been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for physician/practitioner services/specialist and a 20% coinsurance for outpatient diagnostic 
tests/radiological diagnostic services.  
 
You have been asked to pay a $45 copayment for a specialist office visit and a 20% coinsurance of the allowed 
amount for ultrasounds. The total allowed amount is $152.19. The total coinsurance amount you are being 
asked to pay for an ultrasound is $30.44 ($152.19 x 20% = $30.44). The total amount you are being asked to 
pay $75.44 ($45 + $30.44 = $75.44). A specialist office visit falls within the physician/practitioner 
services/specialist benefit category and ultrasounds falls within the outpatient diagnostic tests/radiological 
diagnostic 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 and coinsurance for a 
specialist office visit and ultrasounds provided by a participating provider on December 2, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive genomic profile (CGP) testing provided 
on May 18, 2020. 
 
You asked the Plan to pre-approve genetic testing. You say that the enrollee's treating physician ordered this 
testing to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service May 18, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve comprehensive genomic profile (CGP) testing provided on 
May 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on June 24, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you were told that you would 
not have to pay this copayment since you were in the hospital. 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 $200 
copayment for ambulance services.  
 
You have been asked to pay a $200 copayment for an ambulance trip. The correct copayment has been applied 
to the services that were provided. An ambulance trip falls within the ambulance 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 an ambulance trip provided by a participating provider on 
June 24, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay more for the core buildups and waive the copayment for the crown.  
 
You asked the Plan to pay more for the core buildups and crowns. You say that you were never informed that 
the allowable cost would be different for in and out-of-network dentists. You say that you were informed you 
would have to pay 50% of the allowable cost of the procedure. The Plan says the claim processed correctly. 
 
We decided that the Plan has to pay more for the core buildups and waive the copayment for the crown.  
 
The allowed amount for one core buildup is $27.50 (80% x $27.50 = $22). This means that the Plan is 
obligated to pay $22 toward this core buildup. The allowed amount for the remaining core buildup is $67 (80% 
$67 = $53.60) This means that the Plan is obligated to pay $53.60 toward this core buildup and you are only 
responsible for $13.40.  
 
The Plan also applied a $25 copayment toward the crown. The $25 copayment is only for preventive and 
diagnostic dental services. The crown is not considered a preventive or diagnostic service. Therefore, we 
decided the Plan has to waive the $25 copayment for the crown. The remaining services processed correctly. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve, and addition to 
lower extremity provided on April 8, 2020. 
 
You asked the Plan to pay for the knee orthosis (L1851) and suspension sleeve (L2397), and addition to lower 
extremity (L2385). You say that the Plan should pay this claim. The Plan denied your request. The Plan says 
the billed date of service is different than the ship date or delivered date. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  

The record does not contain a valid proof of delivery for the supplies provided in this case. The claim date of 
service is not the shipping date or the date of delivery date. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the knee orthosis and suspension sleeve, and addition to lower extremity, provided on claim 
date April 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 3, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the enrollee 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the Plan. 
 
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 April 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown and core buildup provided on February 19, 2020. 
 
You asked the Plan to pay for the crown and core buildup. You say that the source of the pain was an old 
crown and the repair was completed. You say that $750 should be approved for payment. 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 the crown 
and core buildup provided on February 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lower extremity orthosis (L2385) provided April 9, 2020. 
 
You asked the Plan to pay for a lower extremity orthosis. You say that the item was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the item billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or proof of delivery which support medical necessity for 
the supplies provided in this case. The delivery ticket submitted is not itemized. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a lower extremity orthosis (L2385) provided April 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not currently require intensive physician and nursing oversight only in an IRF. Your renal function appears 
within normal range, your hemoglobin is stable and your medical conditions are stable and do not require 
intensive IRF monitoring. You may benefit from multiple therapies such as physical and occupational therapy 
but the documentation does not support that your endurance level can tolerate an intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health aide services (S9122) provided from January 2, 
2020, to April 26, 2020. 
 
You asked the Plan to pay for home health aide services. You say that you were told to find your own 
caregiver. The Plan denied your request. The Plan says these services were custodial and the provider is not 
certified for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. The rules also say 
that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the 
provider or supplier is enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The record shows that the services at issue were custodial in nature 
and the provider of these services is not enrolled in the Medicare program. Based on this information, we 
decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we 
decided that the Plan does not have to pay for home health aide services (S9122) provided from January 2, 
2020, to April 26, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays and ultrasounds provided by a 
participating provider on March 18, 2020. 
 
You asked the Plan to waive the copayment for x-rays and ultrasounds. You say that you do not know why 
your copayment is so high. The Plan denied your request. The Plan says the correct copayments have been 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for outpatient diagnostic tests/x-rays and a $125 copayment for outpatient diagnostic 
tests/radiological diagnostic service.  
 
You have been asked to pay a $20 copayment for x-rays and a $125 copayment for ultrasounds. The total 
amount you are being asked to pay is $287.82 ($227.82 (113.91 x 2 ultrasounds = $227.82) + $60 ($20 x 3 x-
rays = $60) = $287.82). X-rays falls within the outpatient diagnostic tests/x-rays benefit category and 
ultrasounds falls within the outpatient diagnostic tests/radiological diagnostic service 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 x-rays and ultrasounds provided by a participating provider 
on March 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
June 11, 2020, to June 15, 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 services 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 $380 
copayment per day for days 1 through 5, for covered hospital care.  
 
You have been asked to pay $1,520 ($380 copayment x 4 days) for the inpatient hospital care 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 inpatient hospital care provided from June 11, 2020, to 
June 15, 2020.