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

We decided that the Plan does not have to pay for eyeglasses provided on June 2, 2021.
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says you must see a Plan vision provider to obtain the benefit.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by the Plan vision care provider. We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by the Plan's
vision care provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on
June 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain 
(70450) provided on July 4, 2021. 
 
You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this claim was not billed with an 
appropriate modifier as required by Medicare rules. 
 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 70450 
is a column II code to column I code 70496. 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 the computed tomography (CT) scan of the head or brain (70450) 
provided on July 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammography provided on 
July 14, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic mammography. You say that it is the same exam 
you have had in past years with no copay. You say this is the done in the same room with the same machine as 
your routine mammogram. 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 $75 
copayment for diagnostic procedures and tests.  
 
You have been asked to pay a $75 copayment for a diagnostic mammography. A diagnostic mammography 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 a diagnostic mammography provided on July 14, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the corneal pachymetry test you received 
on June 4, 2021. 
 
You asked the Plan to waive the copayment for the corneal pachymetry test. You say that you should not be 
charged for this test since you already paid a copayment for the specialist visit. The Plan denied your request. 
The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for 
this test ($13.27) 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 $100 
copayment for ultrasounds.  
 You have been asked to pay a $100 copayment for the corneal pachymetry test. The corneal pachymetry test is 
a type of ultrasound. Your specialist copayment only covers the office visit from the doctor- it does not include 
any diagnostic imaging that you may receive. 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 corneal 
pachymetry test you received on June 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure 
(CPAP) machine rental from April 30, 2021, through August 30, 2021. 
 
You asked the Plan to waive the coinsurance for the CPAP machine rental. You say that you did not have to 
pay a rental fee the last time you bought a CPAP machine. 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 10% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a monthly charge of $8.30, which is 10% of the allowed amount for the CPAP 
machine rental ($83 allowed amount x 10% coinsurance = $8.30). The CPAP machine rental 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 the continuous positive airway pressure (CPAP) machine rental from April 30, 
2021, through August 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you received on July 22, 2019. 
 
You asked the Plan to waive the copayment for the lab services. You say that this was part of your annual 
wellness visit, so there should not be an extra copayment. 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 $10 
copayment for lab services.  
 
According to your contract, an annual wellness visit is a visit to develop or update a personalized prevention 
plan based on your current health and risk factors.  It does not include lab services.  Separate cost sharing 
applies for lab services you may receive. You have been asked to pay a $10 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 on July 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the hysterectomy procedure you had on 
January 20, 2021, and the computed tomography (CT) scan of the abdomen and pelvis you had on March 1, 
2021. 
 
You asked the Plan to waive the copayments for the hysterectomy and the CT scan. You say that during the 
hysterectomy procedure, the nicked your bladder.  You stated that you have been having bladder problems ever 
since the surgery.  You stated that you do not think you should be liable because these services were needed 
due complications from that surgery. The Plan denied your request. The Plan says you were charged these 
copayments 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 $250 copayment for outpatient surgery and a $150 copayment for diagnostic imaging.  
 
You have been asked to pay a $250 copayment for the hysterectomy and a $150 copayment for the CT scan. 
These copayments apply regardless of the reason for the 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 
copayments for the hysterectomy procedure you had on January 20, 2021, and the computed tomography (CT) 
scan of the abdomen and pelvis you had on March 1, 2021.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for the ferumoxytol injections provided from 
May 21, 2021, through May 28, 2021. 
 
You asked the Plan to reduce the cost sharing for the ferumoxytol injections. You say that you thought if the 
procedure was approved you would not have to pay so much. You say, had you known, you would have gotten 
a different medication. 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 20% coinsurance for Medicare Part B prescription drugs. The contract also clearly says that you must pay a $295 
copayment for hospital observation services, which include intravenous injections.  
 
You have been asked to pay 20% of the allowed amount for the coinsurance for the ferumoxytol injections. The 
ferumoxytol injections fall within the Medicare Part B prescription drugs benefit category. You have also been 
asked to pay $295 for the hospital injection services. Hospital injection services fall in the Outpatient Hospital 
Services benefit category.  
 
Date of Service Service Allowed Amount 20% Coinsurance Copayment 
May 21, 2021 Drug $4,589.05 $917.81  
May 21, 2021 Injection   $295 
May 28, 2021 Drug $4,589.05 $917.81  
May 28, 2021 Injection   $295 
 
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 ferumoxytol injections provided from May 21, 2021, 
through May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased from an online retailer on May 
30, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you are covered up to $500 every three years for 
hearing aids. Your bill is $499, and the hearing aids are necessary. The Plan denied your request. The Plan says 
this online retailer is not under contract with the health plan and is not certified with Medicare. A provider or 
supplier must be enrolled in the Medicare program in order for items or services to be covered. 
 
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 plan?s coverage rules apply in this case. The Plan pays for 
hearing aids only when they are received from a provider within the Plan?s network.  
 
We looked at the file and the Plan's rules. The online retailer in question is not a Medicare-certified or 
Medicare-participating provider. The online retailer is not part of the Plan?s network. Based on this 
information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we 
decided that the Plan does not have to pay for the hearing aids purchased from an online retailer on May 30, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received from an out-of-network 
provider on July 12, 2021. 
 
You asked the Plan to pay for the out-of-network dental services. You say that this dentist took your insurance 
card, so you thought it would be covered.  You said that you cannot pay this bill. The Plan denied your request. 
The Plan says dental services with out-of-network providers are not covered.  The Plan says that they sent you 
a listing of network dentists on both June 2, 2021, and June 23, 2021, prior to you receiving these out-of-
network services. 
 
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.  Your contract requires that you use network providers. Therefore, we 
decided that the Plan does not have to pay for dental services you received from an out-of-network provider on 
July 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90837) provided from January 2, 
2021, to June 23, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that you were not aware the provider who 
rendered the services were OON. The Plan denied your request. The Plan says prior authorization was not 
obtained for these services rendered by an OON provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 psychotherapy services (90837) provided from 
January 2, 2021, to June 23, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit services (99214) provided on April 9, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit services. You say that these services were medically reasonable 
and necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these 
services rendered by an OON provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 office visit services (99214) provided on April 
9, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient hospital services received from 
October 20, 2020 to October 22, 2020. 
 
You asked the Plan to waive the copayments for the services. You say that you were told by a customer service 
representative that your deductible was met. The Plan denied your request. The Plan says there was an 
outpatient stay rather than an inpatient stay that affected how the claim was paid. 
 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 outpatient surgery.  
 
You have been asked to pay $452.04 for the services. The services fall within the outpatient surgery and 
outpatient therapy benefit category. You had not met the outpatient deductible yet.  The additional charges are 
for non-covered self-administered drugs. 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 outpatient 
hospital services received from October 20, 2020 to October 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88305, 88312) provided December 12, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the billed codes are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 88305, & 88312 are not supported in the medical record. Specifically, payment for this 
service was included in the facility payment.  
 
 
 
 Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (88305, 88312) provided  
December 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
(A0998) provided on May 26, 2021. 
 
You asked the Plan to pay for the ambulance response without transport. You say that you should not be 
responsible for this cost and do not recall having these services on this date. The Plan denied your request. The 
Plan says the ambulance benefit is a transportation benefit. When transport is not provided, there is no payable 
service. 
 
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 May 26, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Documentation supports that you received assistance in the home from an ambulance team on the date in 
question and declined transport to the hospital or the closest treatment facility. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on 
May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental crown you received on June 23, 2021. 
 
You asked the Plan to pay for the dental crown.. You say that this service was necessary for your overall 
health.  You also stated that you don't know how you exhausted your benefit with the minimal dental services 
you have received. The Plan denied your request. The Plan says you have exhausted your annual dental benefit.  
The Plan wrote you a letter explaining how you met your $100 annual maximum.  Specifically, the Plan 
advised that the following amounts have already been paid for the dental services you have received this year: 
periodontal scaling and root planing ($210), a root canal ($446.00), a crown on May 20, 2021 ($534.50), 
another crown on June 7, 2021 ($309.50).  This totals $1500, so you have exhausted your annual dental 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you have exhausted your annual dental 
benefit. Therefore, we decided that the Plan does not have to pay for the dental crown you received on June 23, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit services provided on June 7, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home visit services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 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 home visit services provided on June 7, 2021 
by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on  
April 19, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 The Plan must follow Medicare rules. Medicare rules say that CPs are required to document a consultation with 
the primary or attending physician or the attempt to make such a consultation. There is no documentation in 
this record supporting consultation or attempt at consultation was performed. Therefore, we decided that the 
Plan does not have to pay for the psychotherapy services (90832) provided on April 19, 2021.