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

 
We decided that the Plan does not have to pay for an office visit (99213) and laboratory services (83861) 
provided on October 28, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and laboratory services. You say that when you called you were 
told that the patient did not need a referral to be seen and now the claim is not being paid. The Plan denied your 
request. The Plan says this provider is not a network provider with the Plan, and they have also determined that 
these services are not urgent or emergent, nor were they approved in advance. The Plan also says that the 
services were not authorized by network/primary care providers. 
 
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 (99213) and laboratory services 
(83861) provided on October 28, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0364) and radiographic/surgical implant index (D6190) provided on August 13, 2021. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation and radiographic/surgical implant 
index. You say that the implant procedure was the only option you had to keep an important lower molar due to 
its location. You also say that you feel entitled to full coverage for the work that was done. 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 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. Therefore, we decided that the Plan does not have to pay for the cone 
beam computed tomography (CT) capture and interpretation (D0364) and radiographic/surgical implant index 
(D6190) provided on August 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a primary care physician (PCP) office visit 
provided on November 22, 2021. 
 
You asked the Plan to waive the deductible for the PCP office visit. You say that you were not made aware of 
the deductible when you enrolled in the Plan. The Plan denied your request. The Plan says the correct amount 
was applied to your deductible. 
 
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 $203 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
Services, Including Doctor's Office Visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $203 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the PCP office visit was rendered on 
November 22, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a primary 
care physician (PCP) office visit provided on November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 31, 2021. 
 
You asked the Plan to pay for the lab services. You say that the patient had active coverage with the plan so 
this should be covered. The Plan denied your request. The Plan says you billed these lab services with an 
incorrect Place of Service. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
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 member's face-to-face service was rendered in a laboratory setting. 
Therefore, we decided that the Plan does not have to pay for lab services provided on March 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a mepolizumab 1mg (J2182) injection 
provided on October 11, 2021. 
 
You asked the Plan to waive the coinsurance for the mepolizumab 1mg (J2182) injection. You say that the 
services should be covered in full as you disagree with the charges. The Plan denied your request. The Plan 
says the coinsurance applied correctly based on the services administered. 
 
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 prescriptions drugs and the administration of them. 
 
 
  You have been asked to pay a 20% coinsurance for a mepolizumab 1mg (J2182) injection (the allowed amount 
is $2,966.42 x 20% = $593.28). Mepolizumab injections fall within the Medicare Part B prescriptions drugs 
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 a mepolizumab 1mg (J2182) 
injection provided on October 11, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiology services provided on August 16, 2021. 
 
You asked the Plan to pay for the cardiology services. You say that the services were unrelated to the patient's 
hospice diagnosis. The Plan denied your request. The Plan says the patient was enrolled in hospice on the date 
of service in question. 
 
 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 cardiology services provided on August 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 15, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee's doctor sent the labs to your 
facility and the claim should be paid. The Plan denied your request. The Plan says the rendering and referring 
providers are both out-of-network providers and the enrollee's primary care physician did not refer for this 
service. Also, the service provided 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 laboratory services provided on March 15, 2021, 
by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on June 29, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you did not request 
the transport and you should not be responsible for the copayment. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $300 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance transportation services provided on June 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-rays of the spine provided on October 
12, 2021. 
 
You asked the Plan to waive the copayment for the X-rays. You say that you did not have the X-rays done in a 
hospital. 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 $100 
copayment for basic radiological services at an outpatient hospital facility.  
 
You have been asked to pay a $100 copayment for the X-rays. Please note that the file shows the location was 
an outpatient facility. The X-rays 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 X-rays of the spine 
provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up (D2950) provided on November 17, 2021. 
 
You asked the Plan to pay for the dental service. You say that you were not aware that this service would not 
be covered. You say that you are on a fixed income. You also say that you cannot afford to pay this bill. The 
Plan denied your request. The Plan says core build up is not a covered service. 
 
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 core build up is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up 
(D2950) provided on November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient pharmacy telehealth visit 
provided on May 10, 2021. 
 
You asked the Plan to waive the copayment for the outpatient pharmacy telehealth visit. You say that you 
spoke with the pharmacist on the phone and they did not help your situation. 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 $30 
copayment for each specialist visit, including telehealth visits.  
 
You have been asked to pay a $30 copayment for the outpatient pharmacy telehealth visit. the outpatient 
pharmacy telehealth visit 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 an outpatient pharmacy 
telehealth visit provided on May 10, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
June 21, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that when you enrolled in the Plan you 
were informed there were no copayments. 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 $90 
copayment for emergency services.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls 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 an emergency room (ER) visit 
provided on June 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services 
provided from August 24, 2021, to September 9, 2021. 
 
You asked the Plan to waive the copayment for the SNF services. You say that this stay should be covered 
since it's for a different condition than your previous stay. You say that you were not advised how benefit 
periods work. 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 $0 per 
day for days 1-20 and $167 per day for days 21-100 for each skilled nursing facility (SNF) benefit period. A benefit period ends when you havent had any skilled care in a SNF for 60 days in a row. 
 
The file shows your first stay lasted 21 days from June 7, 2021, to June 28, 2021. Your second stay lasted 16 
days from August 24, 2021, to September 9, 2021. Since 60 days had not passed between stays, this is 
considered the same benefit period. Therefore, you have been asked to pay $167 per day for days 22-37 of SNF 
services. The total for this stay is $2,672 ($167 copayment x 16 days = $2,672). The SNF services falls within 
the Skilled Nursing Facility (SNF) 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 skilled nursing facility (SNF) services provided from August 24, 2021, to September 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81551) provided November 3, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx is covered in males with previous 
negative prostate biopsy who are being considered for repeat biopsy. 
 
We looked at the file and Medicare rules. There was no record of a previous negative prostate biopsy. Based on 
this information, we decided that Medicare rules for coverage of the genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for genetic testing (81551) provided November 3, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the office visit (99203), the x-ray 
examinations of the feet (73630 x 2), the tendon sheath injection (20550), the dexamethasone sodium 
phosphate injection (J1100), and the triamcinolone acetonide injection (J3301) provided on October 21, 2021 
and November 2, 2021. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
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% coinsurance for each out-of-network (OON) 
Medicare-covered visit with a primary care physician (PCP) or specialist.  
 
You have been asked to pay $102.10 (Plan allowed amount of $257.87 x 40% coinsurance) for the Medicare-
covered out-of-network specialist visit provided. This amount is less than the applicable coinsurance for these 
services provided. 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 office visit (99203), the  
x-ray examinations of the feet (73630 x 2), the tendon sheath injection (20550), the dexamethasone sodium 
phosphate injection (J1100), and the triamcinolone acetonide injection (J3301) provided on October 21, 2021 
and November 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
August 29, 2021, to September 3, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that your wife was 
admitted into an emergency room (ER) on August 20, 2021, where she was treated and transferred a few days 
later to a rehabilitation facility, where she apparently had a fall and was transferred to a different hospital. You 
also say that you do not feel that you should pay this bill as your wife should have been sent back to the 
previous hospital ER. The Plan denied your request. The Plan says you were 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 $220 copayment per day for days one to seven of a hospital stay for your area and plan.  
 
The enrollee has been asked to pay a $220 copayment per day for inpatient hospital services for a total of four 
day, which totals $880 ($220 x 4 = $880). 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 
inpatient hospital services provided from August 29, 2021, to September 3, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the alternative medicine services provided on September 29, 2021, and 
October 13, 2021. 
 
You asked the Plan to pay for the alternative medicine services. You say that you were told your cost share 
would be a $20 copayment for each visit, for up to 25 visits. The Plan denied your request. The Plan says that 
the claims processed 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 enrollees must pay a $20 copayment for Routine Acupuncture and Naturopathy 
services. Based on the Plan contract, you cannot be asked to pay more than a $20 copayment for each visit for 
the acupuncture and/or naturopathy services. Therefore, we decided that the Plan has to pay for the alternative 
medicine services provided on September 29, 2021, and October 13, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99335) provided on 
September 13, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the rendering physician is a 
hospital physician with the group and depends upon the hospital staff to verify eligibility and to obtain the 
proper authorization from the patient's insurance company. The Plan denied your request. The Plan says this 
provider is not a network provider with the Plan and the services were not referred by a network provider or 
rendered in an in-network facility. The Plan also says that they have also determined that these services are not 
urgent or emergent, nor were they approved in advance. 
 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 domiciliary or rest home visit (99335) provided 
on September 13, 2021, by an out-of-network (OON) provider.