Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker provided on January 5, 2020. 
 
You asked the Plan to pay for the walker. You say that you bought it from this provider because it was cheaper. 
The Plan denied your request. The Plan says that this provider is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who 
is not enrolled in the Medicare Program. 
 
The purchase was not made with a supplier who is enrolled in the Medicare program. Therefore, we decided 
that the Plan does not have to pay for the walker provided on January 5, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for home health care provided on February 
25, 2020, and March 31, 2020. 
 
You asked the Plan to waive the coinsurance for home health care. You say that you were told that the services 
would be fully covered. 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 10% 
coinsurance for home health agency care.  
 
You received home health care on February 25, 2020. The total allowed amount is $700.90 and 10% of that is 
$70.08.  
 
You received home health care on March 31, 2020. The total allowed amount is $2,957.47 and 10% of that is 
$295.70. 
 
The total amount you owe is: $365.78. 
 
You have been asked to pay the total coinsurance amount of $365.78 for home health care. Home health care 
falls within the home health agency 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 coinsurance 
for home health care provided on February 25, 2020, and March 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing amount for the Prolia injection. 
 
You asked the Plan to waive the cost sharing amount for Prolia. You say that you were advised you would only 
be responsible for a $28 copayment. The Plan denied your request. The Plan says there is a 20% coinsurance of 
the plan allowed amount for Medicare Part B prescription drugs. The Plan also says Medicare Part B drugs may 
require prior authorization or step therapy. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay 20% coinsurance for Prolia. Prolia falls within the Medicare Part B prescription 
drugs 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 amount for the Prolia injection.  
 
Your complaint about receiving misinformation from the Plan 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 pay for MRSA screening tests (87641) infectious agent detection by 
nucleic acid (DNA or RNA), not otherwise specified (87798) infectious agent drug susceptibility phenotype 
prediction (87900) provided October 28, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that the specimen was obtained in an office 
setting and the specimen was sent to the laboratory to perform tests ordered. Please review the medical records 
and reconsider the claim for payment. The Plan denied your request. The Plan says the records do not support 
the billed 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  is not supported in the medical record. Specifically, the submitted claim form indicates 
the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation 
and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory 
results submitted indicate the specimen was collected on 09/19/2019 and received by the lab on 09/20/2019. 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for MRSA screening tests (87641) 
infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified (87798) infectious agent 
drug susceptibility phenotype prediction (87900) provided October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for wound care provided on December 5, 
2019. 
 
You asked the Plan to pay for the physician's services for wound care. The Plan denied your request. The Plan 
says you 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 
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 physician's services for wound care provided on December 5, 
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional core buildup and additional crowns provided 
on March 5, 2020. 
 
You asked the Plan to pay for the additional core buildup and additional crowns. You say that the enrollee 
suffers from chronic pain. You say that he has severe attrition and acid erosion due to medications he was 
prescribed. The Plan denied your request. The Plan says two crowns have already been paid. The Plan also says 
that two core buildups have also been approved for payment. 
 
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 two crowns per calendar year. The Plan paid for two crowns and approved the two core buildups for those 
crowns provided on March 5, 2020, which exhausted the benefit. Therefore, we decided that the Plan does not 
have to pay for the additional core buildup and additional crowns provided on March 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ambulance trip provided by a participating provider on June 30, 2020.You asked the Plan to waive the copayment foran ambulance trip. You say that you said you could drive your father. You say that the hospital forced your father to take the ambulance.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). The enrollee's contract with the Plan clearly says that enrollees must pay a $275 copayment for ambulance services. The enrollee has been askedto pay $182.69, which is less than your copayment amount of $275 copayment for an ambulance trip. An ambulance trip falls within the ambulance services 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 copayment foran ambulance trip provided by a participating provider on June 30, 2020.We note your complaint about your father being forced to use the ambulance. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vision care provided on May 18, 2020. 
 
You asked the Plan to waive the copayment for vision care. You say that you received a diabetic eye exam and 
should not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for each covered eye exam and a $0 copayment for diabetic retinopathy screenings. 
 
The medical records show that you received vision care beyond a diabetic eye exam on May 18, 2020. 
Therefore, you are responsible to pay the $50 copayment.  
 
You have been asked to pay a $50 copayment for vision care. Vision care falls within the vision 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 vision care provided on May 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fora thyroid stimulating hormone test provided on February 14, 2020.You asked the Plan to pay forlab test. You say that this testing was undertaken as part of your standard physical examination, so you had every expectation that it would be covered.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not covered for screening purposes and you declined to request authorization from the Plan prior to service.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, lab test, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.You were given advanced notice that this testing may not be covered and declined to request prior authorization from the Plan. Therefore, we decided that the Plan does not have to pay fora thyroid stimulating hormone test provided on February 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on 
December 5, 2019. 
 
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that you were informed if 
you send in your dental exam information you would be reimbursed. You say that you want to be reimbursed 
$140. The Plan denied your request. The Plan says you did not have active coverage on the date of service. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the prophylaxis and periodic oral 
evaluation provided on December 5, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on May 4, 2020.You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 psychotherapy 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 psychotherapy services provided on May 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Allosure testing services provided to the enrollee on 
March 16, 2020. 
 
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found in this case, there was no documentation that rejection was a concern or that allosure testing was 
requested. On 3/11/20 creatinine was down to 1.13. The requested allosure test was done 3/16/20 but no 
documentation supports the rationale in light of the improving renal function. The review has determined that 
the enrollee did not meet the criteria for coverage of this test. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Allosure testing services provided to the enrollee on March 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0427) provided 
on March 4, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were not told you 
would have to pay for the ambulance services. The Plan denied your request. The Plan says you were charged 
this cost sharing 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 $220 
copayment for each ambulance trip. You had 1 ambulance trip. The Plan charged you $220 for these 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 ambulance services (A0427) provided on March 4, 
2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on April 10, 
2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you cannot afford the charges. 
The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency care. Emergency care 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 emergency care provided on 
April 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pay forradiology services (CPT 70450) provided to the enrollee on May 28, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysCPT code 70450 is supported as being performed, but it is not supported as being distinct from CPT code 70496.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, we have confirmed that code 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plandoes not haveto pay forradiology services (CPT 70450) provided to the enrollee on May 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided
on May 16, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that this was medically necessary and were 
treated by the medics. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 16, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the service provided on May 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport provided to the enrollee on January 24, 
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 this claim was not filed timely.  
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. The record shows that a claim for this 
service was not filed until March 30, 2020 (the waiver of liability was not signed until June 19, 2020). This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for ambulance transport provided to the enrollee on 
January 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Indomethacin, 50mg, provided on June 1, 2020.You asked the Plan to pay forthe self-administered drug. You say that the self-administered drugs that you received need to be rebilled through the pharmacy benefit that you carry.The Plan denied your request. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan says the requested drug is not covered under Medicare Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay forself-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forthe Indomethacin, 50mg, provided on June 1, 2020.Benefits for the self-administered drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services you received on 
April 5, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the hospital told you that 
you had to go home via ambulance, but you could have had your husband drive you. 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 $325 
copayment for ambulance services.  
 
You have been asked to pay a $325 copayment for the ambulance services. This copayment applies regardless 
of the reason for the transport. 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 ambulance services you 
received on April 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the pelvic ultrasound you had on May 6, 
2020. 
 
You asked the Plan to waive the copayment for the pelvic ultrasound. You say that you have had this procedure 
many times in the past and it has been covered. The Plan denied your request. The Plan says this service was 
covered; however, your cost sharing obligation is more than the allowed amount for this service. 
 
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 $160 
copayment for Medicare-covered radiological diagnostic services, including ultrasounds.  
 
You have been asked to pay the full amount for the ultrasound you had, because the allowed cost is less than 
your $160 copayment obligation. 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 pelvic ultrasound you 
had on May 6, 2020.