Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out of network specialist office visit 
provided on January 27, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you thought the provider 
was in network. The Plan denied your request. The Plan says the copayment applied is 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 $55 
copayment for each out of network Medicare covered specialist visit.  
 
You have been asked to pay $55 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors 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 out of network specialist office visit provided on January 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
February 28, 2022, to March 29, 2022. 
 
You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. 
The Plan denied your request. The Plan says the up to 100 days each benefit period is covered for inpatient 
services in a SNF. The Plan says the benefit period ends when you have not been an inpatient at any hospital or 
SNF for 60 days in a row. The Plan also says that the benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from February 5, 
2021, to February 27, 2022. The Plan has covered 100 days of SNF care.   
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from February 28, 2022, 
to March 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71250 billed for date of service March 12, 
2022. 
 
You asked the Plan to pay for procedure code 71250. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 71250 is bundled into payment for 
code 71275. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71250 
is a column II code to column I code 71275. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 71250 billed for date of service March 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on October 1, 2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 1, 2021. Therefore, 
we decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on October 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service January 21, 
2022. 
 You asked the Plan to pay for procedure code 70480. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70480 is bundled into payment for 
code 70450. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70480 
is a column II code to column I code 70450. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70480 billed for date of service January 21, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services billed with codes 72125, 73502, 73562 and 73552 
for date of service July 17, 2020. 
 
You asked the Plan to pay for services provided on July 17, 2020. You say that this claim was denied as a 
duplicate in error. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 5, 2020. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare billing rules have not been met. Therefore, we decided 
that the Plan does not have to pay for services billed with codes 72125, 73502, 73562 and 73552 for date of 
service July 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on February 17, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost-sharing you are being charged is 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 a $45 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office (as 
permitted under Medicare rules). Covered services include consultation, diagnosis, and treatment by a 
specialist. The provider billed in the amount of $73 and the allowed amount is $39.50, which is less than the 
copayment amount. Therefore, results in the total cost-sharing amount of $39.50.  
 
 
 You have been asked to pay a $39.50 copayment, which is less than the copayment for office visit. Office visits 
fall 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 office visit on February 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wrist/hand orthosis provided on March 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for wrist/hand orthosis. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 wrist/hand orthosis at issue in this appeal. The Plan did not pre-approve 
the wrist/hand orthosis at issue. We found no exception that would require the Plan to pay for the wrist/hand 
orthosis. Therefore, we decided that the Plan does not have to pay for wrist/hand orthosis provided on March 2, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says a wheelchair ramp is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay $80 more for the deluxe frames (V2025), polycarbonate or equal lens 
(V2784), anti-reflective coating (V2750), and progressive lens (V2781) provided on March 31, 2022. 
 
You asked the Plan to pay more for the glasses. You say that your vision coverage for eyeglass lenses and 
frames is $200 per year, but the Plan only paid $120. The Plan denied your request. The Plan says that the 
submitted charge was $719.90, after the $200 allowance, $519.90 remains. The Plan also says that you were 
given a 20 percent discount by the in-network retailer, which leaves you responsible for $415.92. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $200 for the purchase and fitting of eyeglasses and pair of lenses or contact 
lenses. 
 
We looked at the file and the Plan's rules. The record shows that the Plan only paid $120 for your glasses, and 
does not show that your full $200 allowance had been exhausted. Based on this information, we decided that 
the Plan's rules for coverage of the glasses have been met. Therefore, we decided that the Plan has to pay $80 
more for the deluxe frames (V2025), polycarbonate or equal lens (V2784), anti-reflective coating (V2750), and 
progressive lens (V2781) provided on March 31, 2022.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on November 19, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you felt no 
need to be transported to the hospital. The Plan denied your request. The Plan says since there was no transport, 
ambulance charges are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 19, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on November 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transportation from January 3, 
2022, to March 12, 2022. 
 
You asked the Plan to waive the copayments for ambulance transportation. You say that you should not have to 
pay for these services because they were medically necessary. The Plan denied your request. The Plan says you 
pay a $255 copayment for each one-way Medicare-covered ground or air ambulance trip. 
 
 
 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 $255 
copayment for Ambulance Services.  
 
You have been asked to pay a $765 copayment for ambulance transportation ($255x3 trips=$765). Ambulance 
transportation falls 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 
copayments for ambulance transportation from January 3, 2022, to March 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dialysis services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the dialysis services. You say that you would like to stay with the same 
provider for your services. The Plan denied your request. The Plan says the requested provider is an OON 
provider, and the OON provider has already transitioned the enrollee to the in-network provider. Also, the 
proximity and location of the in-network provider is within the service area. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the dialysis services to be provided by an out-of-network (OON) provider.  Your complaint about your experience with the in-network provider 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for portable oxygen equipment provided from 
February 14, 2022, to April 14, 2022. 
 
You asked the Plan to waive the coinsurance for the oxygen equipment. You say that you were under the 
impression that the equipment was free. 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 advanced durable medical equipment (DME), including oxygen concentrators. 
 
 
 
 
 Item Allowed Amount 20% Coinsurance 
Oxygen Concentrator (E1390)  February 14, 2022 $81.12 $16.22 
Portable Oxygen Device (E0431)  February 14, 2022 $15.62 $3.12 
Oxygen Concentrator (E1390)  March 14, 2022 $81.12 $16.22 
Portable Oxygen Device (E0431)  March 14, 2022 $15.62 $3.12 
Oxygen Concentrator (E1390)  April 14, 2022 $81.12 $16.22 
Portable Oxygen Device (E0431)  April 14, 2022 $15.62 $3.12 
Total:  $58.02 
 
You have been asked to pay $58.02, which is 20% of the allowed amount for the oxygen equipment. The 
oxygen equipment falls 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 portable oxygen equipment provided from February 14, 
2022, to April 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a motorized scooter. 
 
You asked the Plan to pre-approve a motorized scooter. You say that you cannot fit in the scooter you have. 
The Plan denied your request. The Plan says your current wheelchair and scooter are for the correct weight 
class. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a motorized scooter and a motorized wheelchair. Both a motorized scooter and a 
motorized wheelchair serve the same purpose as a motorized scooter. Therefore, we decided that the Plan does 
not have to pre-approve a motorized scooter.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from September 17, 2020, to September 30, 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 provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our coder 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 reviewer found that the available documentation does 
not sufficiently support that the enrollee required medical management. The records do not support a Physical 
Therapy/Occupational Therapy (PT/OT) function score of 0-5. The records do not show a stage 3 pressure 
ulcer and two skin treatments, with a nursing function score of 0-5. 
 
We looked at this coder's review, the file, and Medicare rules. The records do not support the use of PDPM 
score IEIB1. 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 pay for skilled nursing facility (SNF) services 
provided to the enrollee from September 17, 2020, to September 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services (97110, 97530, 97140) 
provided on January 19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the PT services. You say that this was a post-surgery follow-up at the doctor's 
office who performed surgery. You say that the doctor was in network. You also say that it was necessary to 
determine further treatment. The Plan denied your request. The Plan says the services denied correctly. 
 
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, nor your Primary Care Physician (PCP). 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 physical therapy (PT) 
services (97110, 97530, 97140) provided on January 19, 2022, 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 of the head and neck 
provided on December 28, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you cannot afford the copayment. 
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 $150 
copayment for radiological diagnostic services, including ultrasounds.  
 
You have been asked to pay $82.48, which is less than the $150 copayment for the ultrasound. The 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 of the head and neck provided on December 
28, 2021.