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

We decided that the Plan does not have to pay for the inpatient hospital admission and services provided on
June 29, 2021, to July 1, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the out-of-network care. You say that these services were necessary, and this
claim should be paid. The Plan denied your request. The Plan says out-of-network services are only covered in
certain limited circumstances. The inpatient care in this case was not urgent/emergent or pre-approved.
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 had network providers
available who could have provided 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 inpatient hospital admission and services
provided on June 29, 2021, to July 1, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 13,
2021.
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges
being so high. 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 $150
copayment for radiological diagnostic services, including ultrasounds.
You have been asked to pay the allowed amount of $123.74, which is less than the $150 copayment 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
October 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (93000) provided on 
October 7, 2021. 
 
You asked the Plan to waive the copayment for the electrocardiogram. You say that the services should be 
covered. 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 $30 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 
 
 You have been asked to pay a $15.81 copayment for an electrocardiogram, which is less than the $30 stated in 
the Plans contract. Electrocardiograms 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 an electrocardiogram 
(93000) provided on October 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110) provided on July 27, 2021, 
through August 9, 2021. 
 
You asked the Plan to pay for the therapeutic exercises. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code for 
the services rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as 
services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the 
qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the therapeutic exercises have not been met. Specifically, the record shows that these claims were 
billed by a nurse practitioner while the services were rendered by a PTA. It is not appropriate for a nurse practitioner to bill for the services of a PTA because the nurse practitioner does not meet the qualifications of a 
therapist. Therefore, we decided that the Plan does not have to pay for the therapeutic exercises (97110) 
provided on July 27, 2021, through August 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested wheelchair and accessories cannot be approved, as you can walk around 
the home with a cane. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair is not medically reasonable or necessary. Our physician reviewer found the 
documentation notes drug and alcohol use, but is not clear on the extent of use. You report current marijuana 
and alcohol use, and the details of the extent of this use are not documented. Therefore, it is not clear that you 
would be able to safely maneuver the requested device.  The documentation is not clear that the use of the requested device will significantly improve MRADLs in the 
home, as the home assessment notes that the bathroom doorway is tight. 
 
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 a power wheelchair and accessories.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx test provided to the enrollee on March 24,
2021.
You asked the Plan to pay for the services. You say that this can help predict the likelihood that the prostate
cancer will be found by a biopsy. The Plan denied your request. The Plan says there was no documented result
of a prior prostate biopsy.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient
information in the record to determine if Medicare rules for coverage of the SelectMDx test provided to the
enrollee on March 24, 2021 have not been met. Despite the records being requested by the plan, the provider
has not provided any justification for the rendered testing.. Therefore, we decided that the Plan does not have to
pay for the SelectMDx test provided to the enrollee on March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the visual field exam and visit (92083, 
99214) provided on June 23, 2021. 
 
You asked the Plan to waive the copayment for the vision services. You say that this was a diabetic eye 
screening and should have been provided at no cost to you. The Plan denied your request. The Plan says this 
exam was not billed as a screening and was billed in relation to a medical diagnosis. This claim was processed 
correctly, and your copayment was assessed in accordance with your contract. 
 
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 $35 
copayment for Medicare-covered exams to diagnose and treat diseases of the eye.  
  
You have been asked to pay a $35 copayment for the vision services. The claim information submitted does not 
identify the service provided as a diabetic eye screening. This claim was billed with a glaucoma diagnosis in 
relation to these services. Therefore, these vision services fall within the Medicare-covered exams to diagnose 
and treat diseases of the eye 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 visual 
field exam and visit (92083, 99214) provided on June 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of X-ray services coded 71045 provided on 
September 2, 2021. 
 
You asked the Plan to pay for an additional unit of X-ray services. You say that you would like this claim 
reprocessed. The Plan denied your request. The Plan says the documentation supports one unit of the X-ray 
services coded 71045-26 that was previously paid. 
 
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 an additional billed unit of CPT code 71045 is not supported in the medical record. Specifically, 
the documentation supports that one X-ray was performed but there is no evidence a second was performed as 
billed. Based on this information, we decided that Medicare rules for coverage of an additional unit of X-ray 
services have not been met. Therefore, we decided that the Plan does not have to pay for an additional unit of 
X-ray services coded 71045 provided on September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam image capture (D0364) provided on 
November 8, 2021. 
 
You asked the Plan to pay for the dental imaging. You say that this service should be covered by your plan, and 
you are awaiting reimbursement. The Plan denied your request. The Plan says this service is not covered by 
your dental benefit. 
 
  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 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 cone 
beam image capture (D0364) provided on November 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) admission provided from 
September 20, 2021, to October 21, 2021. 
 
You asked the Plan to pay for the SNF admission. You say that the services are coverable under the Medicare 
Act. The Plan denied your request. The Plan says the enrollee did not receive any skilled services on the dates 
of service in this case. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SNF admission have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the skilled 
nursing facility (SNF) admission provided from September 20, 2021, to October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam (D0140) provided on October 28,
2021.
You asked the Plan to pay for the limited exam. You say that you thought this would be a follow-up to a
previous exam and would be covered in full. The Plan denied your request. The Plan says you had a previous
limited oral exam on March 24, 2021, which was covered at that time. This service may only be covered once
per plan year, so the limited exam provided on the date in question exceeds what is covered by your benefit.
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. The Plan can cover one
limited exam to evaluate a problem (D0140) per plan year.
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited exam is requested in a
frequency that exceeds what is covered under this benefit. Documentation shows that you have had a previous
limited exam in 2021, which was covered by the Plan at that time. Therefore, we decided that the Plan does not
have to pay for the limited oral exam (D0140) provided on October 28, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
September 19, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you went to more than 
one hospital on the same day. You also say you should not have to pay for double emergency room 
copayments. 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 $120 
copayment for emergency room services.  
 
 Emergency room services provided by different hospitals are each subject to the copayment amount. You have 
been asked to pay a $120 copayment for an emergency room visit. An emergency room visit 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 an emergency room 
visit provided on September 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiac monitoring services provided on 
July 21, 2021. 
 
You asked the Plan to waive the copayment for cardiac monitoring services. You say that you feel that this is 
duplicate billing. 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 $10 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay a $10 copayment for cardiac monitoring services. Cardiac monitoring services 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 cardiac monitoring services provided on July 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a denosumab (Prolia) injection provided 
on September 28, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were not expecting the 
coinsurance for the injection. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for each Part B non-chemotherapy drug, including injectable osteoporosis drugs.  
 
 
 You have been asked to pay $251.66, which is 20% of the allowed amount for the injection ($1,258.32 allowed 
amount x 20% coinsurance = $251.66). The injection 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 coinsurance for a denosumab (Prolia) injection 
provided on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99205), the x-ray exam of the shoulder 
(73020), the x-ray exam of the wrist (73100), the annual depression screening (G0444), and the alcohol and/or 
substance misuse structured assessment (G0396) rendered by the out-of-network (OON) provider on May 13, 
2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided 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 office visit (99205), the x-ray exam of the shoulder (73020), the x-ray exam 
of the wrist (73100), the annual depression screening (G0444), and the alcohol and/or substance misuse 
structured assessment (G0396) rendered by the out-of-network (OON) provider on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental item. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the requested lower denture is not medically necessary. 
 
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 the dental 
item when the services are medically necessary and reasonable.  
 
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 dental item. Our reviewer says that 
the requested partial denture is not medically necessary. Our physician reviewer found the provided 
documentation indicates there is insufficient bone to support the remaining teeth and the requested partial denture. Therefore, the reviewer found that the partial denture is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental item have not been met. Specifically, the file does not indicate that 
there is sufficient bone to support the remaining teeth and partial denture. Therefore, we decided that the Plan 
does not have to pre-approve a partial lower denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on April 21,
2021.
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 the enrollee did not have prior authorization for out of network physician 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided 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 out of network physician services provided on
April 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator 
(K0606) provided from June 18, 2021, to August 18, 2021. 
 
You asked the Plan to waive the coinsurance for the automatic external defibrillator. You say that the services 
should be covered. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
 
 
 
 You have been asked to pay a 20% coinsurance for an automatic external defibrillator ($5,862.9 x 20% = 
$1,172.58). Automatic external defibrillators 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 an automatic external 
defibrillator (K0606) provided from July 18, 2021, to August 18, 2021.