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

 
We decided that the Plan does not have to reduce the copayment for a diagnostic eye exam provided on 
November 1, 2021. 
 
You asked the Plan to reduce the copayment for the eye exam. You say that your copayment should only be 
$15 for the annual exam. 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 $45 
copayment for each outpatient visit for services to diagnose and/or treat a disease or condition of the eye.  
 
The records show that you were seen specifically for dry eyes. Therefore, you have been asked to pay a $45 
copayment for the eye exam. The eye exam falls within the Vision 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 reduce the copayment for a diagnostic eye exam provided on November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 20, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 provided on January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology, gross and microscopic examination 
(88302) and special stains (88312) provided March 25, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee went to an in-network provider 
and you are the laboratory that received the specimen for testing. The Plan denied your request. The Plan says 
this claim was processed with the correct cost share applied per the Evidence of Coverage. 
 
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 $750 deductible which applies to Outpatient diagnostic tests and 
therapeutic services and supplies.  
 
The item or service you asked the Plan to pay for falls within the benefit category Outpatient diagnostic tests 
and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is $750 deductible which applies to Outpatient diagnostic tests and therapeutic services and 
supplies. This cost sharing is a contractual obligation that had not been met at the time the laboratory services was received on March 25, 2022. Therefore, we decided that the Plan does not have to pay for the surgical 
pathology, gross and microscopic examination (88302) and special stains (88312) provided March 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided June 2, 2021. 
 
You asked the Plan to waive the copayment for the cataract surgery. You say that the copayment should be 
waived. The Plan denied your request. The Plan says the correct cost-sharing 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 $75 
copayment for outpatient surgery.  
 
You have been asked to pay a $75 copayment for the cataract surgery. The cataract surgery falls within the 
outpatient surgery 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 June 2, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial glossectomy (41120) provided November 2, 2021. 
 
You asked the Plan to pay for the surgical procedure. You say that you are requesting an appeal for the denied 
service. You were told this was covered by the Plan. The Plan denied your request. The Plan says the services 
was rendered by a provider who is not certified with Medicare. If you go to a provider who is not eligible to 
participate in Medicare, you will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the partial glossectomy (41120) provided 
November 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (A0427) and ground mileage (A0425) provided on March 22, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that you should not be responsible for this bill. 
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 ambulance service, advanced life support, emergency 
transport (A0427) and ground mileage (A0425) provided on March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the medical eye exam (92014) provided on 
March 14, 2022. 
 
You asked the Plan to reduce the copayment for the eye exam. You say that this was a routine eye exam and 
should only have a $15 copayment. The Plan denied your request. The Plan says this claim was processed 
correctly, and your copayment was assessed in accordance with your contract. 
 
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 Medicare-covered outpatient visit for services to diagnose and/or treat a disease or 
condition of the eye.  
 
You have been asked to pay a $45 copayment for the eye exam. The eye exam in question was billed as a 
medical (non-routine) eye exam, and the records provided show that medical concerns were discussed during 
this visit. That means that the eye exam falls within the Medicare-covered outpatient visit for services to 
diagnose and/or treat a disease or condition of the eye 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 
copayment for the medical eye exam (92014) provided on March 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for ambulance transportation provided on 
February 9, 2022. 
 
You asked the Plan to reduce the copayment for the ambulance transportation. You say that your copayment 
should only be $265. 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 ambulance service.  
 
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 reduce the copayment for 
ambulance transportation provided on February 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
clinical effectiveness has not been demonstrated. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
Bone marrow aspirate services during spine surgery were requested. 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 the requested services. Our physician reviewer found that bone marrow 
aspirate remains experimental when used as bone graft material in spine surgery. More research is needed to 
show safety and efficacy. Therefore, the request is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient consultation services provided on January 28, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient consultation services. You say that the facility should have obtained 
prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained for these 
services. 
 
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 inpatient consultation services provided on 
January 28, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ophthalmic ultrasound provided on 
April 14, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you feel the charge should be 
included with the office visit 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 $55 
copayment for each standard X-ray and ultrasound.  
 
 
 
 
 
 
 You have been asked to pay $5, which is less than the $55 copayment for the ultrasound. The ultrasound 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 an ophthalmic ultrasound provided on April 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 19, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from February 24, 2022, to February 28, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that your provider filed this claim with 
Medicare Part B. You say that you need this portion of your bill to be filed with Medicare Part D coverage. 
You also say that the provider will not re-file this with your Medicare Part D coverage. The Plan denied your 
request. The Plan says the drugs in this case are considered self-administered.  The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan 
also says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided in an outpatient setting from February 24, 2022, to February 28, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory tests provided on January 17, 2022. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because this testing was 
performed for non-covered screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnostic laboratory tests must be ordered by 
the physician who is treating the beneficiary.  
 We looked at the file and Medicare rules. The records submitted do not include a signed order or clear intent to 
order for the specific lab codes billed on this claim. Based on this information, we decided that Medicare rules 
for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for 
laboratory tests provided on January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88305) provided September 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 88305 is not supported in the medical record. Specifically payment for this service is 
included in payment to the facility. Based on this information, we decided that Medicare rules for coverage of 
the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(88305) provided September 11, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on February 2, 2021. 
 
You asked the Plan to pay for psychotherapy. You say that you depend on the facility for timely notification of 
patients health insurance coverage. You say that the physician provided medically necessary services in good 
faith and is entitled to reimbursement. The Plan denied your request. The Plan says a corrected claim must be 
submitted within 1 year. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a corrected claim for psychotherapy was not filed until February 23, 2022. This means 
that more than one calendar year from the date of service and original claim submission had passed before a 
corrected claim was filed. Therefore, we decided that the Plan does not have to pay for psychotherapy provided 
on February 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided March 9, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you were stabilized at home and did not 
require transport. The Plan denied your request. The Plan says this service is not covered when there is no 
transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.   
The ambulance company did not provide transport services on March 9, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 January 10, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthoses (L0631, L1930, L2820) provided March 27, 2022 to 
March 29, 2022. 
 
You asked the Plan to pay for the orthoses. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for orthoses (L0631, L1930, L2820) 
provided March 27, 2022 to March 29, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for a transitional care visit provided on October 25, 2021. 
 
You asked the Plan to pay for the transitional care visit. You say that you understand you did not follow the 
rules in obtaining authorization. The Plan denied your request. The Plan says that you must receive your care 
from a network provider and a provider who is not part of the Plan's network, will not be covered. 
 
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. Specifically, the Plan did not submit the 2021 Evidence of Coverage or 
Summary of Benefits. This means that we could not confirm the enrollee was aware that authorization was 
required for out-of-network services. It is the burden of the Health Plan to substantiate their denial with 
evidence. In this case, the denial has not been substantiated so we must find in your favor Therefore, we 
decided that the Plan has to pay for a transitional care visit provided on October 25, 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.