Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the placement of intra-socket biological dressing 
to aid in hemostasis or clot stabilization (D7922) provided on May 5, 2021. 
 
You asked the Plan to reimburse you for the biological dressing to aid in hemostasis or clot stabilization. You 
say that you were told something different every time that you called. The Plan denied your request. The Plan 
says the biological dressing to aid in hemostasis or clot stabilization is not listed as a covered 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 the biological dressing to aid in 
hemostasis or clot stabilization is not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to reimburse you for the placement of intra-socket biological dressing to aid in hemostasis 
or clot stabilization (D7922) provided on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on 
September 28, 2021. 
 
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 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 $30 
copayment for each specialist visit.  
 
You have been asked to pay a $30 copayment for the specialist visit 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 office visit (99214) provided on  
September 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided August 
23, 2021. 
 
You asked the Plan to pay for a pneumatic compression device. You say that please review the attached 
medical records and reprocess the claim for payment as the medical records show medical necessity for the 
provided device. The Plan denied your request. The Plan says pneumatic compression device is not covered by 
Medicare to prevent deep vein thrombosis during and/or following surgery. 
 The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. The enrollee used the equipment in the facility during 
and/or after surgery. Payment for this service would have been included under the facility claim. Payment for 
this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that 
the Plan does not have to pay for a pneumatic compression device (E0676) provided August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on May 6, 
2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you cannot afford the 
charges. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $40 
copayment for each specialist visit.  
 
You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a specialist office visit provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) provided on 
August 6, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be 
covered in full as all you have was an office visit. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on 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 $40 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
 
 You have been asked to pay a $40 copayment for a specialist office visit. The record indicates that the services 
were rendered by a psychiatry and neurology specialist. Specialist office visits fall 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 a specialist office visit (99213) provided on August 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing services provided on September 17, 2021. 
 
You asked the Plan to pay for the hearing services. You say that you did not know the provider was out of 
network. The Plan denied your request. The Plan says hearing services and hearing aids must be provided by a 
participating network provider. Prior authorization may be required for hearing aids. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when provided by a participating network provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing services were not provided by a 
participating network provider. Based on this information, we decided that the Plan's rules for coverage of the 
hearing services have not been met. Therefore, we decided that the Plan does not have to pay for hearing 
services provided on September 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgery services for removal of implantable 
defibrillator electrodes (33244) and replacement of implantable defibrillator system (33249) provided on June 
25, 2021. 
 
You asked the Plan to pay for assistant surgery services. You say that assistant surgery services were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for assistant surgery 
services have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) codes 33244 and 33249. The Medicare Fee Schedule Database contains a 
surgical indicator of 1 for these procedures.  This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be 
paid. Based upon this information, we find that Medicare coverage criteria for assistant surgery services have 
not been met. Therefore, we decided that the Plan does not have to pay for assistant surgery services for 
removal of implantable defibrillator electrodes (33244) and replacement of implantable defibrillator system 
(33249) provided on June 25, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nerve conduction test you received on 
October 27, 2021. 
 
You asked the Plan to waive the copayment for the nerve conduction test. You say that you already paid a $5 
copayment for the office visit and you assumed this covered all services you received in the office.  You said 
that the doctor did not let you know that there would be additional cost for this service. 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 $50 
copayment for diagnostic procedures and tests in an office setting or imaging center.  
 
You have been asked to pay a $50 copayment for the nerve conduction test. The nerve conduction test falls 
within the diagnostic procedures and tests in an office setting or imaging 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 the nerve conduction test you received on 
October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on July 12, 2021. 
 
You asked the Plan to pay for the eye refraction. You say that it was your understanding that eye refractions are 
part of your vision test for Macular Degeneration. You say you have been having problems with your eyes and 
without this test they would not have found that you have the beginning stages of Macular Degeneration. The 
Plan denied your request. The Plan says refractive services are not part of the routine eye exam and not 
included in the item description. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when 
done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided 
that the Plan does not have to pay for an eye refraction provided on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite, one surface, posterior filling 
(D2391x2), a resin-based composite, two surfaces, posterior filling (D2392x5) and a resin-based composite, 
three surfaces, posterior filling (D2393x2) provided on October 21, 2021, to October 25, 2021. 
 
You asked the Plan to pay for resin-based composite fillings. You say that you contacted the Plan prior to 
having dental work done. You say that no one advised you would only be covered for 2 fillings in a year. You 
also say you cannot afford to pay for these services. The Plan denied your request. The Plan says you have 
been issued reimbursement for 2 fillings. The Plan will not pay for additional fillings. 
 
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. The Plan covers two resin-
based composite fillings per calendar year.  
 We looked at the file and Medicare rules. The EOC confirms that you are covered for 2 resin-based composite 
fillings per calendar year. The records show that you had eleven (11) resin-based composite fillings. The Plan 
paid for 2 fillings; therefore, you have exhausted the maximum benefit for this service. Based on this 
information, we decided that the Plan's rules for coverage of resin-based composite fillings have not been met. 
Therefore, we decided that the Plan does not have to pay for a resin-based composite, one surface, posterior 
filling (D2391x2), a resin-based composite, two surfaces, posterior filling (D2392x5) and a resin-based 
composite, three surfaces, posterior filling (D2393x2) provided on October 21, 2021, to October 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you received at a freestanding 
lab on Jult 8, 2021. 
 
You asked the Plan to waive the copayment for the lab services. You say that you have never paid for labs in 
the past. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan 
says that because the allowed amount for these labs ($17.49) is less than your copayment obligation, you are 
responsible for the full allowed 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 $25 
copayment for lab services at a freestanding lab.  
 
You have been asked to pay a $25 copayment for the lab 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 lab services you received at a freestanding lab on Jult 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
October 8, 2020, to October 11, 2020. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the Payment Integrity post-service post-pay clinical validation audit shows that the provider has 
reported inpatient hospital services with the incorrect DRG. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 190 (CHRONIC OBSTRUCTIVE 
PULMONARY DISEASE WITH MCC). 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. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found although the provider documented acute on chronic respiratory failure with 
hypoxia, reasonable support within the health record must be present for that diagnosis. It is appropriate for 
facilities to ensure that documentation is complete, accurate and appropriately reflects the patient's clinical 
conditions. DRG 192: CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC is more 
appropriate in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from October 8, 2020, to October 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on January 
19, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you do not believe the 
enrollee received these services on this date. The Plan denied your request. The Plan says this copayment was 
charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $290 copayment for ambulance services.  
 
The enrollee has been asked to pay a $290 copayment for the ambulance services. The billing records show that 
the enrollee was transported to his home on the date of service in question. 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 for ambulance services provided on January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 5, 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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in a skilled nursing facility setting 
and should have been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on August 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) you 
received on November 6, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that you were not advised of any out-of-
pocket costs and you cannot pay this bill. 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 $150 
copayment for MRIs.  
 
You have been asked to pay a $150 copayment for the MRI. 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 magnetic resonance imaging (MRI) you received on November 6, 2021.  
 Your complaint about these services not being paid under your Medical Financial Assistance Program 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: 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 based on IRF criteria. The Plan states the 
enrollee's medical and therapy needs could be met in a skilled nursing unit. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 review has determined that the complexity of the enrollee's nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care.  The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee 
will be able to fully participate in and benefit from the 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for the ultrasound you had on October 20, 
2021. 
 
You asked the Plan to reduce the cost sharing for the ultrasound. You say that you believe the Plan should have 
paid 80% of the cost of this service. The Plan denied your request. The Plan says you were charged this 
copayment correctly.  The Plan says that because the allowed amount for the ultrasound ($77.58) is less than 
your copayment obligation, you are responsible for the full allowed 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 $160 
copayment for radiological diagnostic services.  
 
You have been asked to pay a $160 copayment for the ultrasound. The ultrasound falls within the 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 reduce the cost sharing for the ultrasound you 
had on October 20, 2021.