Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from March 2, 
2020 to March 7, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
charges because you were not given a choice as to which kind of room you wanted. 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 $290 
copayment for days 1-7 for inpatient hospital care.  
 
You had an inpatient hospital stay from March 2, 2020, to March 7, 2020. Therefore, you are responsible to 
pay a $290 copayment for days 1-5 (March 2, 2020, to March 6, 2020). $290 (copayment) x 5 (inpatient days) 
= $1,450. 
 
You have been asked to pay the total copayment amount of $1,450 for an inpatient hospital stay. An inpatient 
hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an inpatient hospital stay from March 2, 2020 to March 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positron emission tomography (PET) scan provided to the 
enrollee on May 20, 2020. 
 
You asked the Plan to pay for this service. You say that a PET scan was medically necessary. The Plan denied 
your request. The Plan says Medicare coverage criteria were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary. 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 this service. Our reviewer 
says that Medicare coverage criteria were not met. Our physician reviewer found there is no documentation 
regarding the clinical care of this patient with metastatic urothelial carcinoma. Without indication of where she 
is in her treatment paradigm no clear indication for PET scan is apparent. The service is not reasonable or 
medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we 
decided that the Plan does not have to pay for a positron emission tomography (PET) scan provided to the 
enrollee on May 20, 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 
January 6, 2019. 
 
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that your maximum cost 
should be 40%. You say that you cannot be billed for costs not stated in the summary of benefits. The Plan 
denied your request. The Plan says the claim processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is only obligated to pay 60% 
of the allowed amount for your covered preventive dental services from an out-of-network provider. You are 
responsible for any amount above the dental coverage limit. Therefore, we decided that the Plan does not have 
to pay for the prophylaxis and periodic oral evaluation provided on January 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the prophylaxis and periodic oral evaluation provided 
on January 9, 2020. 
 
You asked the Plan to pay more for the prophylaxis and periodic oral evaluation. You say that your maximum 
cost should be 40%. You say that you cannot be billed for costs not stated in the summary of benefits. The Plan 
denied your request. The Plan says the claim processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is only obligated to pay 60% 
of the allowed amount for your covered preventive dental services from an out-of-network provider. You are 
responsible for any amount above the dental coverage limit. Therefore, we decided that the Plan does not have 
to pay more for the prophylaxis and periodic oral evaluation provided on January 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) provided on 
January 16, 2020. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test. You say that none of this work was needed. 
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 
adjunctive pre-diagnostic test (D0431) provided on January 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion services provided from December 19, 2019, to 
December 25, 2019. 
 
You asked the Plan to pay for home infusion therapy. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says this code is not valid for Medicare purposes. 
 
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 S9501 is Home infusion therapy, antibiotic, antiviral, or 
antifungal therapy; once every 12 hours; administrative services, professional pharmacy services, care 
coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem  
 
We find that CPT code S9501 is not a valid code for Medicare purposes. S codes are unique temporary codes 
established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare 
uses another code for reporting of, and payment for, these services. Based on this information, we decided that 
Medicare rules for coverage of home infusion therapy management have not been met. Therefore, we decided 
that the Plan does not have to pay for home infusion services provided from December 19, 2019, to December 
25, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test and an 
outpatient surgery provided by a participating provider on March 27, 2020. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test and an outpatient surgery. You say 
that you were treated poorly and you do not feel like you should pay. 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 $85 
copayment for outpatient diagnostic tests/radiological diagnostic service and a $250 copayment for outpatient 
diagnostic tests/surgery.  
 
You have been asked to pay a $85 copayment for an outpatient diagnostic test and a $250 copayment for an 
outpatient surgery. The total amount you are being asked to pay is $335 ($85 + $250) = $335). An outpatient 
diagnostic test falls within the outpatient diagnostic tests/radiological diagnostic service benefit category. An 
outpatient surgery falls within the outpatient diagnostic tests/surgery 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 diagnostic test and an outpatient surgery provided by a 
participating provider on March 27, 2020.  
 
 
 
We note your complaint about feeling like you received poor services. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positron emission tomography (PET) scan provided to the 
enrollee on April 28, 2020. 
 
You asked the Plan to pay for a PET scan. You say that a PET scan was medically necessary. The Plan denied 
your request. The Plan says Medicare coverage criteria were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary. 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 a PET scan. Our reviewer 
says that Medicare coverage criteria are not met. Our physician reviewer found insufficient medical records 
were provided to show a PET scan was medically necessary in this enrollee. There are no biopsy results 
indicating histology (such as adenocarcinoma, squamous cell, neuroendocrine) or prior imaging. A PET scan is 
not always indicated for the work-up of malignancy. The service is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not 
have to pay for a positron emission tomography (PET) scan provided to the enrollee on April 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure 
(CPAP) machine and supplies provided from April 1, 2020, to June 1, 2020. 
 
You asked the Plan to waive the coinsurance for CPAP machine and supplies. You say that you are disputing 
these charges. The Plan denied your request. The Plan says the coinsurance amounts you are being charged are 
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 20% 
coinsurance for in-network CPAP machine and supplies. The allowed amounts of these claims total $548.87, 
resulting in a total coinsurance obligation of $109.79. 
 
You have been asked to pay 20% coinsurance for CPAP machine and supplies. CPAP machine and supplies 
fall within the Durable Medical Equipment (DME) and Related Supplies benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for a continuous positive airway pressure (CPAP) machine and supplies 
provided from April 1, 2020, to June 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology colorectal screening (81528) provided on 
November 20, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for oncology colorectal screening. You say that you provided medically necessary 
services referred by another provider. The Plan denied your request. The Plan says prior authorization must be 
obtained for non-emergent services rendered by an out-of-network provider. 
 
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 oncology colorectal screening (81528) 
provided on November 20, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on July 22, 2020. 
 
You asked the Plan to pay for the first intraoral periapical x-ray. You say that you did not know that x-rays 
were not covered by the dental portion of your Medicare policy. The Plan denied your request. The Plan says 
your benefit has been exhausted. The Plan also says that your $1,000 benefit max was met before the 
processing of this service. 
 
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 offers a $1,000 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit while processing this claim for the July 22, 2020 date of service, and your annual maximum 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral 
periapical x-ray provided on July 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle-foot orthosis with stabilizer (L1971, L3170) 
provided to the enrollee on May 19, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for an ankle-foot orthosis with 
stabilizer (L1971, L3170) provided to the enrollee on May 19, 2020.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transportation services provided on April 13, 2020. 
 
You asked the Plan to pay for the services provided. You say that you were having blood pressure problems. 
The Plan denied your request. The Plan says that the documentation does not show that other means of 
transportation could endanger your health. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules. 
 
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 the services provided. Our physician 
reviewer found that you received non-emergent ambulance transportation to home from the hospital. There is 
documentation of concern for you for the transit home. Therefore, the transportation was medically necessary 
and reasonable. 
 
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 provided have been met. Therefore, we decided that the Plan has to 
pay for the ambulance transportation services provided on April 13, 2020.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0480 provided on September 17, 
2019. 
 
You asked the Plan to pay for the drug 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 supported by the documentation. 
 
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 G0480 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug 
class(es), including metabolite(s) if performed. 
 
We find that CPT code G0480 is not supported in the medical record. Specifically, the documentation 
submitted did not include a valid physician order/lab requisition form or medical records signed by the ordering 
physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0480 provided 
on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the triamcinolone acetonide injection services coded J3301 
and the therapeutic, prophylactic, or diagnostic injection services coded 96372 provided on October 18, 2019. 
 
You asked the Plan to pay for the triamcinolone acetonide injection services and the therapeutic, prophylactic, 
or diagnostic injection services. 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 supported by the documentation. 
 
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 J3301 and 96372 is not supported in the medical record. Specifically, the medical 
records do not include the administration of triamcinolone acetonide, injection, not otherwise specified, 10 mg. 
Therefore, the service code J3301 and the units billed cannot be verified. The documentation submitted did not 
include documentation of Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); 
subcutaneous or intramuscular; therefore, code 96372 cannot be verified. 
Based on this information, we decided that Medicare rules for coverage of the triamcinolone acetonide 
injection services and the therapeutic, prophylactic, or diagnostic injection services have not been met.  
Therefore, we decided that the Plan does not have to pay for the triamcinolone acetonide injection services 
coded J3301 and the therapeutic, prophylactic, or diagnostic injection services coded 96372 provided on 
October 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services rendered on January 28, 
2019, to January 29, 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 the claim has not been processed by the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed 
that the claim has not been processed by the primary insurer. As the secondary insurer, the Plan cannot be held 
responsible for these services until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for the outpatient hospital services rendered on January 28, 2019, to 
January 29, 2019.