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

 
We decided that the Plan does not have to pay more for a hearing aid provided on December 9, 2021. 
 
You asked the Plan to pay more for a hearing aid. You say that you should be paid $500 for each ear. The Plan 
denied your request. The Plan says the member was issued payment of $500. The Plan also says that the service 
is a covered benefit, but the enrollee has exceeded limits set in the subscriber agreement. 
 
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 The Plan rules say that the Plan pays up to a $500 allowance for hearing aids every 3 years. 
The record shows the Plan paid $500 towards hearing aids purchased on December 9, 2021. Therefore, the 
benefit has been exhausted.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a hearing aid have not been met. Therefore, we decided that the Plan does not have to pay more for 
a hearing aid provided on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on September 07, 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 this cost sharing 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). Your contract with the Plan clearly says that you must pay a $45 
copayment for each specialist visit for Medicare-covered services. Covered services include consultation, 
diagnosis, and treatment by a specialist.  
 
You have been asked to pay a $45 copayment for office visit. This item/service 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 office visit on September 07, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72128 billed for date of service June 9, 2022. 
 
You asked the Plan to pay for procedure code 72128. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 72128 is bundled into payment for code 72129. 
 
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 72128 is a column II code to column I code 72129. 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 72128 billed for date of service June 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99310) provided on 
June 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
this service was rendered by a non-contracted provider, and prior authorization was not obtained. 
 
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 subsequent nursing facility care (99310) 
provided on June 9, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a back injection provided to the enrollee on 
July 13, 2022. 
 
You asked the Plan to waive the copayment for the back injection. You say that the enrollee is on a fixed 
income and cannot afford the charges. The Plan denied your request. The Plan says this cost sharing 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 $200 copayment for outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers.  
 
The enrollee has been asked to pay a $200 copayment for the back injection. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. 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 a back injection provided to the 
enrollee on July 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing provided to the enrollee on June 20, 2022. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support testing of a non-drug analyte as indicated in the code description of 
the code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for validity testing provided to the enrollee on June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like the claim reprocessed for payment. 
The Plan denied your request. The Plan says the rendering provider is an OON provider and there was no 
referral from an in-network provider or an approved authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan 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 an office visit provided on July 15, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and a deductible for an outpatient surgery 
provided on July 12, 2022. 
 
You asked the Plan to waive the copayment and a deductible for an outpatient surgery. You say that you 
disagree with the copayment amount. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $345 copayment for outpatient surgery/Medicare-covered surgery at 
an ambulatory surgical center and a $750 deductible which applies to section 1.2 What is your deductible and 
outpatient surgery/Medicare-covered surgery at an ambulatory surgical center.  
 
The total amount you are being asked to pay towards your deductible is $396.68. The total amount you are 
being asked to pay is $741.68 ($396.68 + $345 = $741.68). This cost sharing is a contractual obligation that 
had not been met at the time an outpatient surgery was received on July 12, 2022. Therefore, we decided that 
the Plan does not have to waive the copayment and a deductible for an outpatient surgery provided on July 12, 
2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from April 9, 2022, to 
April 17, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare 
covered services related or unrelated to the members terminal condition. The Medicare hospice benefit, 
through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of 
discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services 
and all care unrelated to the terminal illness until the first day of the month following the month in which 
hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 3, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for psychotherapy provided 
from April 9, 2022, to April 17, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from October 5, 2021, to 
October 28, 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 that authorization 
was needed, and you cannot afford these bills. The Plan denied your request. The Plan says a 
referral/authorization was not obtained prior to services being rendered. 
 
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 psychotherapy services provided from October 5, 
2021, to October 28, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for office visits and a revascularization 
procedure provided from March 21, 2022, to July 22, 2022. 
 
You asked the Plan to waive the copayments for the office visits and revascularization procedure. You say that 
you were informed there was a billing error. The Plan denied your request. The Plan says this cost sharing 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). Your contract with the Plan clearly says that you must pay a $45 
copayment for physician/practitioner services, including doctor's office visits (specialist).  
 
 Your contract with the Plan also clearly says that you must pay a $225 copayment for outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers. 
 
You have been asked to pay a $45 copayment for each of the 5 office visits, for a total of $225. This 
item/service falls within the physician/practitioner services, including doctor's office visits (specialist) benefit 
category. You have also been asked to pay a $225 copayment for the revascularization procedure. This 
item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 office 
visits and a revascularization procedure provided from March 21, 2022, to July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction (92015) provided on August 22, 2022. 
 
You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says eye refractions are 
only covered by your plan if performed by a participating provider and performed as a routine screening. 
 
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 these services when the refraction is performed during a routine exam. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that the office advised you did not 
receive a routine eye exam, but received a medical eye refraction for the diagnoses of Presbyopia, Drusen 
(degenerative) of macula, bilateral, and Nonexudative age-related macular degeneration, bilateral, intermediate 
dry stage. Based on this information, we decided that the Plan's rules for coverage of the refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the refraction (92015) provided on 
August 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 8, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on June 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that the facility is responsible to obtain the 
authorization and you would like the claim reprocessed for payment. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 a home health visit provided on June 7, 2022, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and copayment for an onabotulinumtoxina 
injection provided on June 9, 2022. 
 
You asked the Plan to waive the coinsurance and copayment for the injection. You say that the treatment is 
effective, and you would like the cost lowered. The Plan denied your request. The Plan says this cost sharing 
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). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs. If administered in the office, the coinsurance applies in 
addition to the office visit member liability. 
 Your contract with the Plan also clearly says that you must pay a $30 copayment for medical care or surgery 
services in a specialty physician's office. 
 
You have been asked to pay $192.82 for the injection, which is 20% of the allowed amount ($964.10 allowed x 
20% = $192.82). This item/service falls within the Medicare Part B prescription drugs benefit category. You 
have also been asked to pay a $30 copayment for the drug administration in an office setting. This item/service 
falls within the medical care or surgery services in a specialty physician's office benefit category. The total for 
the visit is $222.82. 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 and copayment for an 
onabotulinumtoxina injection provided on June 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided from May 10, 2022, to May 20, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the coinsurance. The 
Plan denied your request. The Plan says this cost sharing 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). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME).  
 
You have been asked to pay a 20% coinsurance for DME. The total allowed amount for the DME is $8,904.40. 
The total amount you are being asked to pay $1780.88 ($8904.40 x 20% = $1,780.88). 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 durable medical equipment (DME) provided from May 10, 2022, to 
May 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on June 27, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says this cost sharing 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). Your contract with the Plan clearly says that you must pay a $250 
copayment for each outpatient hospital visit. If you are having surgery in a hospital facility, you should check 
with your provider about whether you will be an inpatient or outpatient. Unless the provider writes an order to 
admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for outpatient 
surgery. Even if you stay in the hospital overnight, you might still be considered an "outpatient." 
 
You have been asked to pay a $250 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery, including services provided at hospital facilities and ambulatory surgical centers 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 outpatient surgery on June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic testing provided on June 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for diagnostic testing. You say that you saw the enrollee in a facility and the facility 
did not obtain a prior authorization. The Plan denied your request. The Plan says services from a non-
participating provider are not covered unless there is a pre-authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 diagnostic testing provided on June 6, 2022, by an 
out-of-network (OON) provider.