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

 
We decided that the Plan does not have to waive the copayment for a duplex scan provided on April 20, 2022. 
 
You asked the Plan to waive the copayment for a duplex scan. You say that this was a covered procedure 
ordered by your doctor for a blood clot. 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 a $130 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).  
 
You have been asked to pay $119.21 for a duplex scan, which is less than the standard $130 copayment. A 
duplex scan 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 duplex scan provided on April 20, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services provided to the enrollee from 
November 16, 2021, to November 30, 2021. 
 
You asked the Plan to pay for the services. You say that the documentation supports the originally coded 
diagnosis of mechanically altered diet while in the facility. The Plan denied your request. The Plan says that the 
medical records submitted do not support the HIPPS code billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has provided no background information supporting their downgrade 
of the Speech Language Pathology (SLP) component. There is no rationale for why their downgraded HIPPS 
code - MKEE1 - is appropriate in this case. The plan has not confirmed why K in the second character slot is 
more appropriate than L. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) 
services provided to the enrollee from November 16, 2021, to November 30, 2021.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transvaginal ultrasound (76830) provided 
on May 11, 2022. 
 
You asked the Plan to waive the copayment for the transvaginal ultrasound. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 You have been asked to pay a $146.06 copayment for a transvaginal ultrasound which is less than the standard 
$160. Transvaginal ultrasounds fall within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a transvaginal ultrasound 
(76830) provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the line dancing classes purchased on January 1, 2022. 
 
You asked the Plan to pay for the line dancing classes. You say that you think line dancing is a good form of 
exercise and is good mentally because when you live by yourself it is very important to socialize with people. 
The Plan denied your request. The Plan says line dancing is not a qualified benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only if the membership is for a qualified health club or fitness facility. 
 
The Plans rules for coverage of gym benefits have not been met because line dancing is not a qualified benefit 
under the 2021 Wellness Allowance. Therefore, we decided that the Plan does not have to pay for the line 
dancing classes purchased on January 1, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reimburse you for a Parkinsons fitness class received on February 1, 2022. 
 
You asked the Plan to reimburse you for the class. You say that this was recommended by your neurologist. 
The Plan denied your request. The Plan says that the SilverSneakers benefit does not allow for individual 
fitness sessions. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits, 
such as group exercise classes. 
 
The Plans rules for coverage of gym benefits have been met because Parkinson's Power hour is a group class, 
not an individual fitness session. This class could be considered a "group exercise class" which is explicitly 
covered by the contract. The plan has not fully substantiated their denial, as they have not given substantial 
proof that the rehabilitation center is not in network for you. Therefore, we decided that the Plan has to 
reimburse you for a Parkinsons fitness class received on February 1, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0481 and 83789) provided on March 25, 
2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical records. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. In 
addition, the Plan says that code 83789 is for specimen validity testing which is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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. Medicare rules also 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 lab 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. In addition, we find that the 
testing described by code 83789 is considered specimen validity testing which is not separately payable. 
Therefore, we decided that the Plan does not have to pay for lab services (G0481 and 83789) provided on 
March 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for speech therapy services (96125) provided 
on April 29, 2022. 
 
You asked the Plan to waive the copayment for the speech therapy services. You say that the services should be 
covered as you disagree with the denial The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for Outpatient rehabilitation services.  
 
 
  You have been asked to pay a $40 copayment for the speech therapy services. Seech therapy services fall 
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 speech therapy services (96125) provided on April 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a scope exam with biopsy provided on 
March 1, 2022. 
 
You asked the Plan to waive the copayment for the scope exam with biopsy. You say that your explanation of 
benefits said you owed $0 so there should not be a copayment. The Plan denied your request. The Plan says the 
proper copayment was applied for the service that was billed. 
 
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 Medicare-covered ambulatory surgical center visit.  
 
  You have been asked to pay a $250 copayment for the scope exam with biopsy. The scope exam with biopsy 
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 a 
scope exam with biopsy provided on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like to appeal the denied claim. The Plan 
denied your request. The Plan says the rendering provider is an OON provider and there was no referral from 
the enrollee's primary care 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 an office visit provided on February 17, 2022, 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 ophthalmological services provided on April 29, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ophthalmological services. You say that the services provided should be 
covered under the facilities authorization. The Plan denied your request. The Plan says the rendering provider 
is an OON provider and there was no 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 the ophthalmological services provided on April 
29, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on December 13, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that the services rendered to the enrollee was 
medically necessary. The Plan denied your request. The Plan says the rendering and referring providers are 
both OON providers. 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 the outpatient services provided on December 13, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on May 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in shower (S5165). 
 
You asked the Plan to pre-approve a walk-in shower. You say that it is difficult for you to get into your tub. 
You have almost fallen a hand full of times. The Plan denied your request. The Plan says the requested item is 
not a Medicare covered benefit. 
 
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 walk-in shower (S5165).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service rendered to the enrollee was medically 
necessary and you would like to claim to be paid. 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 an office visit provided on April 15, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0031U, 0032U, 0033U, 81227, 81230, 
81231, 81232, 81291, 81306, 81328, 81355) provided January 25, 2022. 
 
You asked the Plan to pay for genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the individual codes are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple codes were submitted for a single panel. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for genetic testing (0031U, 0032U, 0033U, 81227, 81230, 81231, 
81232, 81291, 81306, 81328, 81355) provided January 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic nuclear medicine procedure 
provided on March 23, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic nuclear medicine procedure. You say that this 
copayment is too high and need it to be waived. The Plan denied your request. The Plan says the copayment 
that was applied was 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 $350 
copayment for other Medicare-covered diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay a $350 copayment for a diagnostic nuclear medicine procedure. A diagnostic 
nuclear medicine procedure 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 nuclear medicine procedure 
provided on March 23, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on January 22, 
2022. 
 
You asked the Plan to waive the copayment for emergency room services. 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 $90 
copayment for each emergency room visit. Emergency care refers to services that are furnished by a provider 
qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical condition.  
 
You have been asked to pay a $90 copayment for emergency room services. Emergency room services fall 
within the Emergency Care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency 
room services on January 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for An injection to a major joint provided on 
April 5, 2022. 
 
You asked the Plan to waive the copayment for an injection to a major joint. You say that this copayment is too 
high, and you have not had to pay a high copayment like this before when getting an injection. The Plan denied 
your request. The Plan says the copayment that was applied was 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 $250 
copayment for other outpatient procedures and services.  
 
You have been asked to pay a $250 copayment for an injection to a major joint. An injection to a major joint 
fall 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 An injection 
to a major joint provided on April 5, 2022.