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

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on January 
19, 2023. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that you were told you needed to 
return for another ultrasound. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 
copayment for outpatient diagnostic tests, including ultrasounds. 
 
You have been asked to pay a $60 copayment for the breast ultrasound. This item/service falls within the 
outpatient diagnostic tests, including ultrasounds 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 the breast ultrasound provided on January 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA) 
(64625). 
 
You asked the Plan to pre-approve SI joint RFA. You say that the services are necessary. The Plan denied your 
request. The Plan says the requested service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that SIJ Denervation (also called Radiofrequency 
Ablation or RFA) is not considered reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SI joint RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve 
sacroiliac (SI) joint radiofrequency ablation (RFA) (64625).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan provided on September 
09, 2022. 
 
You asked the Plan to pay for a computed tomography (CT) scan. You say that this was medically necessary 
and should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a computed tomography 
(CT) scan provided on September 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0220 and D0230), the 
panoramic radiographic image (D0330), and the extraction (D7140) for tooth #20 provided on January 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you thought the x-rays would be covered 
because when you called, they said x-rays and cleanings were covered. The Plan denied your request. The Plan 
says the denial of payment for these services is correct, because the intraoral radiographic images, the 
panoramic radiographic image, and the extraction are not covered by the Plan. 
 
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 pay for the 
intraoral radiographic images (D0220 and D0230), the panoramic radiographic image (D0330), and the 
extraction (D7140) for tooth #20 provided on January 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network physical therapy visit 
provided on November 25, 2022. 
 
You asked the Plan to waive the copayment for an in-network physical therapy visit. You say that you canceled 
this appointment and spoke to the therapist on the phone. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for an in-network physical therapy visit. This item/service 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. There are medical records showing that you checked in for this service that 
day and received services from this provider. Therefore, we decided that the Plan does not have to waive the 
copayment for an in-network physical therapy visit provided on November 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an in-network electrocardiogram (EKG) 
provided on February 3, 2023. 
 
You asked the Plan to waive the deductible for an in-network electrocardiogram (EKG). You say that you have 
never had to pay a deductible on an EKG before and you do not understand why you have one now. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible which applies to other outpatient diagnostic tests. 
You have been asked to pay $208.11 towards the $250 deductible. 
 
The item or service you asked the Plan to waive the deductible for falls within the other outpatient diagnostic 
tests benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$250 deductible which applies to other outpatient diagnostic tests. This cost sharing is a contractual obligation 
that had not been met at the time an in-network electrocardiogram (EKG) was received on February 3, 2023. Therefore, we decided that the Plan does not have to waive the deductible for an in-network electrocardiogram 
(EKG) provided on February 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit services provided on November 21, 2022, to 
November 22, 2022. 
 
You asked the Plan to pay for home visit services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home visit services 
provided on November 21, 2022, to November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network orthopedic office visit 
provided on January 25, 2023. 
 
You asked the Plan to waive the copayment for an in-network orthopedic office visit. You say that these were 
all follow ups for a surgery, there should not be a copayment. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for an in-network orthopedic office visit. This item/service falls 
within the physician/practitioner services, including doctors 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 in-network orthopedic office visit provided on January 25, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
December 15, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that your diagnosis was 
entered wrong, and should have been for COVID-19. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for in-network emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room visit. This item/service falls within the 
in-network 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 the 
emergency room visit provided on December 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
October 29, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were under the 
impression that you would not have any responsibility. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $310 
copayment for ambulance services. 
 
You have been asked to pay a $310 copayment for the ambulance transportation. This item/service 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 the 
ambulance transportation provided on October 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the debridement procedures provided from 
December 7, 2022, to January 9, 2023. 
 
You asked the Plan to waive the copayments for the debridement procedures. You say that these procedures 
should not be considered surgery. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment per visit, to a hospital outpatient facility. You have been asked to pay a $350 copayment for each debridement procedure provided on December 7, 2022, 
December 14, 2022, December 21, 2022, and January 9, 2023. You have been asked to pay a total of $1,400 
($350 copayment x 4 procedures = $1,400). These items/services fall within the outpatient surgery, including 
services provided at hospital outpatient facilities benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayments for the debridement procedures provided from December 7, 2022, to January 9, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the echocardiogram (EKG) provided on 
November 14, 2022. 
 
You asked the Plan to waive the copayment for the echocardiogram (EKG). You say that you have not been 
charged for this in the past. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for in-network outpatient diagnostic tests provided by an outpatient hospital. 
 
You have been asked to pay a $250 copayment for the echocardiogram (EKG). This item/service falls within the in-network outpatient diagnostic tests provided by an outpatient hospital 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. The record shows this claim was 
approved and you are responsible for the cost share amount. However, since the allowed amount is less than 
the standard copayment, you only owe $52.96. Therefore, we decided that the Plan does not have to waive the 
copayment for the echocardiogram (EKG) provided on November 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83970) related to end-stage renal 
disease (ESRD) provided on November 29, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (83970) related to end-stage renal disease (ESRD) provided on 
November 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdomen and pelvis computed tomography (CT) scan 
with contrast, and lab services provided on September 20, 2022. 
 
You asked the Plan to pay for an abdomen and pelvis computed tomography (CT) scan with contrast, and lab 
services. You say that this is supported in the records. The Plan denied your request. The Plan says that 
unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an abdomen and pelvis 
computed tomography (CT) scan with contrast, and lab services provided on September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 13, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on December 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 21, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
in distress and did not think to check your benefits. You also say you have used the insurance for many years 
are asking to reconsider this charge. The Plan denied your request. The Plan says these services are not a 
covered benefit. 
 
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 November 21, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on January 30, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that this is supported in the records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility care 
provided on January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous, osteo-periosteal, or cartilage graft of the mandible 
or maxilla - autogenous or non-autogenous, by report (D7950) provided on December 27, 2022. 
 
You asked the Plan to pay for dental services. You say that you do not agree with the insurance company 
denying dental services. The Plan denied your request. The Plan says this service is not covered under your 
Plan. 
 
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. Osseous, osteo-periosteal, or 
cartilage graft of the mandible or maxilla - autogenous or non-autogenous, by report (D7950) is not covered 
under the Plans dental benefits. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D7950 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for osseous, osteo-
periosteal, or cartilage graft of the mandible or maxilla - autogenous or non-autogenous, by report (D7950) 
provided on December 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), 
and removal of impacted tooth - completely bony (D7240) provided on December 21, 2022. 
 
You asked the Plan to pay for the dental services represented by codes D0220 and D7240. You say that you did 
not see this dentist on this date of service for the crown. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider.  Therefore, we decided that the Plan does not have to pay for an intraoral - periapical first radiographic image 
(D0220), and removal of impacted tooth - completely bony (D7240) provided on December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient home visit provided on January 17, 2023. 
 
You asked the Plan to pay for a new patient home visit. You say that the provider was not responsible for 
obtaining authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a new patient home visit 
provided on January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 15, 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 say that providers must report services correctly. 
 
Medicare guidelines say that ICD-10-CM has a coding convention that requires the underlying condition to be 
sequenced first, followed by the manifestation. In this case, K74.00 is a manifestation code and cannot be used 
as the primary or first-listed diagnosis code on the claim. Therefore, we decided that the Plan does not have to 
pay for the laboratory services provided on December 15, 2022.