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

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on June 16, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges 
because you have never been charged in the past. 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 $0 
copayment for diagnostic mammograms and a $155 copayment for ultrasounds.  
 
You have been asked to pay the allowed amount of $75.49, which is less than the $155 copayment for an 
ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound provided on June 
16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on May 21, 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 99152 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 99152 is moderate sedation services by physician also 
performing a procedure, patient 5 years of age or older, first 15 minutes. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of 
an independent trained observer to assist in monitoring the patient's level of consciousness and physiological 
status, first 15 minutes. 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 moderate sedation 
services rendered on May 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D4910, D0274) provided by a provider 
that has opted out of Medicare. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial and asking services 
to be covered at 70%. The Plan denied your request. The Plan says you must receive services from a Medicare 
Advantage Participating Dentist. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental 
services (D4910, D0274) provided by a provider that has opted out of Medicare.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot orthotics rendered on August 11, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for the foot orthotics rendered on August 
11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the computed tomography (CT) scan of the 
thorax (71250) provided on June 2, 2020. 
 
You asked the Plan to adjust 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 service 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 $100 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a 
physician's office or at a free-standing facility (such as a radiology center or medical clinic).  
 
You have been asked to pay a $100 copayment for the Medicare-covered radiological diagnostic service 
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 adjust the copayment for the computed tomography (CT) scan of the 
thorax (71250) provided on June 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on September 4, 2019, and 
February 14, 2020. 
 
You asked the Plan to pay for the dental services. You say that you would like reimbursement for these 
services. The Plan denied your request. The Plan says you have already been reimbursed the maximum 
allowance for non-Medicare covered dental services for both 2019 and 2020. 
 
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 $250 annual dental 
benefit maximum for 2019, and a $500 annual dental benefit maximum for 2020. The contracts both say that 
you are responsible for any amount above the dental coverage limit. The record shows that you met the 2019 
annual maximum benefit while processing the claim for the September 4, 2019 date of service, and you met the 
2020 annual maximum benefit while processing the claim for the February 14, 2020 date of service, and your 
annual maximum benefits for 2019 and 2020 have been exhausted. Therefore, we decided that the Plan does 
not have to pay for the dental services provided on September 4, 2019, and February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on June 5, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that there are in-network providers available for 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 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 outpatient services provided on June 5, 2020 by an 
out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit (99282) 
and non-covered service (A9270) provided August 13, 2020. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you are requesting 
financial reimbursement for the poor medical service you received. The disservice at this facility was truly 
unprofessional and uncaring. The Plan denied your request. The Plan says the claim processed with the correct 
cost share applied per the plan benefits. 
 
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 $75 
copay for each Medicare covered emergency room visit.  
 
You have been asked to pay $75 copay for the emergency room services. The emergency room services fall 
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 the 
emergency department visit (99282) and non-covered service (A9270) provided August 13, 2020.  
 
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the breast provided on 
July 2, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound of the breast. You say that you disagree with the 
charges because you feel the service should be considered as a preventative mammogram. 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 $0 
copayment for diagnostic mammograms and a $160 copayment for ultrasounds.  
 
You received an ultrasound of the breast on July 2, 2020. An ultrasound of the breast is considered diagnostic, 
not preventative. Therefore, you are responsible to pay the allowed amount of $100.23, which is less than the 
$160 copayment.  
 
You have been asked to pay $100.23 for an ultrasound of the breast. An ultrasound of the breast falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an ultrasound of the breast provided on July 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 5, 2020, by an OON 
provider. 
 
You asked the Plan to pay for debridement, nursing facility care, and foam dressing. You say that the enrollee 
was referred by an in-network provider. The Plan denied your request. The Plan says rules for payment have 
not been met. 
 
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 case record shows that the enrollee was referred for medical services by an OON provider. Neither the 
referring provider nor the requested provider in this case is a network provider with the Plan. The Plan has 
network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-
approve the item/service at issue. We found no exception that would require the Plan to pay for these 
items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on 
March 5, 2020, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI scan of the cervical spine (72141) and an MRI 
scan of the lumbar spine (72148). 
 
You asked the Plan to pre-approve MRI scans of the cervical and the lumbar spine. You say that these services 
are necessary for neck and low-back pain. The Plan denied your request. The Plan says rules for pre-approval 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 pre-approve MRI scans of the cervical and the 
lumbar spine. Our reviewer says that this request for cervical spine MRI and lumbar spine MRI is not 
medically reasonable and necessary. Our physician reviewer found that the enrollee has been diagnosed with 
cervicalgia and low back pain. Evidence based medical literature would not support this request at this time. 
There are no medical records submitted for review that show emergence of a red flag, physiologic evidence of 
tissue insult or neurologic dysfunction, progressive neurologic symptoms, failure of conservative treatment, or 
that the enrollee is a candidate for invasive interventions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI scans of the cervical and the lumbar spine have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an MRI scan of the cervical spine (72141) and an MRI 
scan of the lumbar spine (72148).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on June 16, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges 
because you were transferred from one facility to another. 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 $250 
copayment for ambulance services.  
 
You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall 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 ambulance services 
provided on June 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6740). 
 
You asked the Plan to pre-approve retainer crowns. You say that you say that you are in pain and that you are 
getting an infection in the tooth. The Plan denied your request. The Plan says the rules for pre-approval have 
not been met. 
 
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 pre-approve 
retainer crowns (D6740).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services (99291, 45915, 93010) provided. 
 
You asked the Plan to pay for hospital services. You say that these services were billed with appropriate 
diagnosis codes. The Plan denied your request. The Plan says these services were not billed with the correct 
primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that, the ICD-10-CM has a coding convention that 
requires the underlying condition be sequenced first, if applicable, followed by the manifestation.  Wherever 
such a combination exists, there is a use additional code? note at the etiology code, and a code first note at 
the manifestation code. 
 
We looked at the file and Medicare rules. The billed primary diagnosis, R65.21, has a code first note, 
requiring the etiology code to be listed first. Based on this information, we decided that Medicare rules for 
coverage of hospital services have not been met. Therefore, we decided that the Plan does not have to pay for 
hospital services (99291, 45915, 93010) provided.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic ultrasound provided on August 19, 2019. 
 
You asked the Plan to pay for the ultrasound, abdominal, real time with image documentation; complete 
(76700). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the 
submitted medical records do not indicate that the ultrasound was performed. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
We looked at the file and Medicare rules. There is no real time image documentation. Based on this 
information, we decided that Medicare rules for coverage of the ultrasound, abdominal, real time with image 
documentation; complete (76700) have not been met. Therefore, we decided that the Plan does not have to pay 
for the diagnostic ultrasound provided on August 19, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 9, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
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 has network providers 
available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on July 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for a CT scan of the abdomen and pelvis 
(74177), a CT scan of the thorax (71260), and an administration of contrast material (Q9967) received on April 
23, 2020. 
 
You asked the Plan to waive the cost-sharing for a CT scan of the abdomen and pelvis, a CT scan of the thorax, 
and an administration of contrast material. You say that you feel you shouldn't have to pay for both CT scans. 
The Plan denied your request. The Plan says the correct cost-sharing was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160 
copayment for each Medicare-covered radiological diagnostic service, not including X-rays, and 20% 
coinsurance for each Medicare-covered Part B drug.  
 
You have been asked to pay a $160 copayment for a CT scan of the abdomen and pelvis, a $136.17 copayment 
for a CT scan of the thorax, and $0.98, or 20% of the Plan-allowed amount of $4.90, for an administration of 
contrast material. A CT scan of the abdomen and pelvis and a CT scan of the thorax fall within the "Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies" benefit category. An administration of contrast 
material 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 for a CT scan of the abdomen and pelvis (74177), a CT scan of the thorax (71260), 
and an administration of contrast material (Q9967) received on April 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on November 5, 2019, by an 
out-of-network provider. 
 
You asked the Plan to pay for the radiology services (72110, 73523). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says you did not request prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. 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 the radiology services provided on November 5, 2019, by an out-of-network 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT scan provided by on July 7, 2020. 
 
You asked the Plan to pay for the CT scan. The Plan denied your request. The Plan says 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 
CT scan. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for a CT scan provided on July 7, 2020.