Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospice services provided to the enrollee from December 1, 
2020, to December 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 this needs to be directly billed to Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospice services provided to the enrollee from December 1, 
2020, to December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy provided on January 26, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for infrared therapy. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 infrared therapy provided on January 26, 2022 by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 
10, 2021. 
 
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 denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for drug testing services provided to the enrollee on November 10, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on December 3, 2021 to January 
3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that your physicians render medical care for 
patients in the facility. These services were medically necessary and should be paid. The Plan denied your 
request. The Plan says unauthorized, non-plan care is not covered. 
 
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 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 medical services provided on December 3, 2021 to January 3, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for all 4 
quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says periodontal scaling and root planing is covered once per 3 calendar years per 
quadrant. The Plan also says that the frequency limit has been reached. 
 
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 and periodontal scaling and root 
planing is covered once per 3 calendar years per quadrant, the frequency limit has been reached. The record 
shows that the Plan paid for periodontal scaling and root planing for all 4 quadrants the enrollee received on March 9, 2020. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root 
planing (D4341) for all 4 quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010), custom fabricated abutment (D6057), abutment supported porcelain fused to metal crown (D6059), 
pontic (D6241), and two retainer crowns (D6751 x2). 
 You asked the Plan to pre-approve an endosteal implant, custom fabricated abutment, abutment supported 
porcelain fused to metal crown, pontic, and retainer crowns. You say that you have tooth pain and need 
bridgework. You also say that you need an implant. The Plan denied your request. The Plan says these services 
are not covered. 
 
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 pre-approve a 
surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment (D6057), 
abutment supported porcelain fused to metal crown (D6059), pontic (D6241), and two retainer crowns (D6751 
x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist visit on December 2, 2021. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you were advised by the doctors 
office that they are an in-network, therefore you should have a $35 copayment not $40. The Plan denied your 
request. The Plan says coinsurance 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 Medicare-covered out-of-network specialist visit.  
 
You have been asked to pay $40, which is less than the standard $55 copayment for specialist visit. The 
specialist 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 specialist visit on December 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for a cystourethroscopy provided on August 4, 
2021. 
 
You asked the Plan to reduce the cost share for a cystourethroscopy. You say that prior to surgery you had a 
meeting with hospital staff and were told you would only owe a $195 copayment. You also say you specifically 
asked about the hospital staff being out-of-network (OON) and the staff said they did not know of any OON 
staff. 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 25% 
coinsurance for out-of-network outpatient surgery at an outpatient hospital.  
 
 The record shows the Plan originally processed the claim incorrectly with a 30% coinsurance. The claim is 
being reprocessed to reflect the correct cost sharing amount. You have been asked to pay 25% coinsurance of 
the allowed amount for a cystourethroscopy. A cystourethroscopy 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 reduce the cost share for a cystourethroscopy provided on August 4, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and your continued care needs can be better 
provided in an outpatient, skilled nursing facility or long-term care facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that your rehabilitation needs can be met safely and provided at a lower intensity 
and alternate setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pelvic x-ray (72170) provided on September 5, 2021. 
 
You asked the Plan to pay for the diagnostic service. You say that the service was billed correctly. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the pelvic x-ray (72170) provided on September 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for enteral formula provided on January 18, 
2022. 
 
You asked the Plan to waive the coinsurance for the formula. You say that you did not have to pay for the 
formula before. 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 durable medical equipment (DME) and related supplies, including formula.  
 
You have been asked to pay $49.25, which is 20% of the allowed amount for the formula ($246.24 allowed 
amount x 20% coinsurance = $49.25). The formula 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 enteral formula 
provided on January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure (D1999), periodontal scaling and 
root planing (D4342) of the lower left quadrant, gingival irrigations (D4921) of the lower right and lower left 
quadrants, and application of desensitizing medicament (D9910) provided on February 15, 2022. 
 
You asked the Plan to pay for the preventive procedure, scaling and planing, gingival irrigations, and 
application of desensitizing medicament. The Plan denied your request. The Plan says your plan does not 
provide benefits for the preventive procedure. The Plan also says that you have exhausted your $2,000 dental 
allowance and are responsible for the remaining amount due. 
 
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 Plan offers a $2,000 combined 
allowance for supplemental preventive and comprehensive dental services every year. The contract says that 
you are responsible for any amount over and above the allowance amount. The record shows that you met the 
annual maximum benefit while processing this claim for the February 15, 2022 date of service and your annual 
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
preventive procedure (D1999), periodontal scaling and root planing (D4342) of the lower left quadrant, 
gingival irrigations (D4921) of the lower right and lower left quadrants, and application of desensitizing 
medicament (D9910) provided on February 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided on November 19, 
2021. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you called prior to your surgery, 
and you were advised there was no cost share. The Plan denied your request. The Plan says coinsurance 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 $550 
copayment per in-network visit.  
 
  You have been asked to pay $240.89, which is less than the standard $550 copayment for cataract surgery. 
Cataract surgery 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 copayment 
for cataract surgery provided on November 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the enrollee requires dialysis 
treatments 3 times per week. You say that the enrollee does not have transportation, economic, or family 
resources. You say that the enrollee's municipality does not provide transportation services to dialysis. You also 
say that the transportation services are medically necessary. The Plan denied your request. The Plan says 20 
one-way trips are covered per year. The Plan also says that the transportation benefit has been exhausted.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional trips to 
go to your dialysis appointments. You also say that you have no one to take you. The Plan denied your request. 
The Plan says 24 trips are covered per year. The Plan also says that the transportation benefit has been 
exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you are unable to locate a pain 
management provider that is closer to you. You also say that you cannot continue to pay out of pocket for 
transportation to the provider's office. The Plan denied your request. The Plan says you are requesting an 
additional 20 miles for a total of 70 miles. The Plan also says that your benefit only allows 50 miles, and you 
have exceeded your benefit limit. 
 
  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the destination is within 50 miles of the pickup location.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage (A0170).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy on November 24, 2021, 
and November 30, 2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you have reached your out-of-
pocket maximum before you had these two appointments. You say that you should not have to pay these 
copayments. The Plan denied your request. The Plan says coinsurance 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 $40 
copayment for each Medicare-covered physical therapy and speech-language therapy visit. You pay these 
amounts until you reach the out-of-pocket maximum.  
 
  You have been asked to pay $80 for physical therapy visits ($40/visit x 2 visits = $80). Physical therapy falls 
within the Outpatient rehabilitation 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 copayment 
for physical therapy on November 24, 2021, and November 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on October 
16, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that the EMT's said Medicare 
would cover the cost of the ambulance, since it was a medically justified emergency. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment for ground ambulance services.  
 
The enrollee has been asked to pay a $250 copayment for ambulance services. Ambulance services fall within 
the Ambulance Services 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 ambulance services provided on 
October 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 11, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning 
modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed appropriately by Medicare coding regulations. 
 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 76705 
is a column II code to column I code 93976. 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 abdominal ultrasound (76705) provided on January 11, 2022.