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

 
We decided that the Plan does not have to waive the copayment for an in-network x-ray provided on August 
08, 2023. 
 
You asked the Plan to waive the copayment for an in-network x-ray. You say that you were treated poorly here, 
therefore you feel you should not have to pay this 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 $30 
copayment for outpatient diagnostic tests and therapeutic services andsupplies. 
 
You have been asked to pay a $30 copayment for an in-network x-ray. This item/service falls within the 
outpatient diagnostic tests and therapeutic services andsupplies 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 x-ray provided on August 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine provided on January 31, 2023. 
 
You asked the Plan to pay for the shingles vaccine. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the vaccine is covered under your part D 
(pharmacy) benefits, not your medical benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on January 
31, 2023.  
 
Benefits for the shingles vaccine 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network injection procedure provided 
on July 31, 2023. 
 
You asked the Plan to waive the copayment for an in-network injection procedure. You say that this should not 
be classified as a procedure, you had injections done in the office. 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 $300 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $300 copayment for an in-network injection procedure. This item/service 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 an in-network injection 
procedure provided on July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each programming device evaluation 
provided on April 25, 2023, to July 28, 2023. 
 
You asked the Plan to waive the copayment for each programming device evaluation. You say that you were 
never charged for these services before. 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 $50 
copayment for each in-network Medicare-covered outpatient diagnostic procedure and test in an office setting. 
 
You have been asked to pay a $50 copayment for each programming device evaluation. This item/service falls within the each in-network Medicare-covered outpatient diagnostic procedure and test in an office setting 
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 
total amount you owe is $100 ($50 copayment x 2 services = $100). Therefore, we decided that the Plan does 
not have to waive the copayment for each programming device evaluation provided on April 25, 2023, to July 
28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each facet joint injection provided on 
March 10, 2023, to March 31, 2023. 
 
You asked the Plan to reduce the copayment for each facet joint injection. You say that you think that the 
copayment should be lower. 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 for Medicare-covered outpatient surgery in an outpatient hospital setting. 
 
You have been asked to pay a $350 copayment for each facet joint injection. This item/service falls within the Medicare-covered outpatient surgery in an outpatient hospital setting 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 total amount you owe is $700 
($350 copayment x 2 services = $700). Therefore, we decided that the Plan does not have to reduce the 
copayment for each facet joint injection provided on March 10, 2023, to March 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - three surfaces, anterior (D2332) 
provided on March 17, 2023. 
 
You asked the Plan to pay for the dental service. You say that you do not agree with the denial of payment for 
the dental service you received. 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. Resin-based composite - three 
surfaces, anterior (D2332) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-
based composite - three surfaces, anterior (D2332) provided on March 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a chemotherapy injection provided on July 
10, 2023. 
 
You asked the Plan to waive the coinsurance for a chemotherapy injection. You say that you disagree with the 
cost share applied. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for a chemotherapy injection. This item/service falls within the 
Medicare Part B prescription 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. You have been asked to pay $1,435.68 coinsurance, which is 20% of the 
allowed amount for a Medicare Part B chemotherapy drug injection ($7,178.40 allowed x 20% = $1,435.68). 
Therefore, we decided that the Plan does not have to waive the coinsurance for a chemotherapy injection 
provided on July 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on June 15, 2023. 
 
You asked the Plan to pay for home health services. You say that this is 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 home health services 
provided on June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy services. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that your doctor recommended 
you check with a nutrition therapist. The Plan denied your request. The Plan says clinicals show you do not 
have any of the covered diagnoses for medical nutrition therapy to be covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mammogram provided on July 19, 2023. 
 
You asked the Plan to waive the copayment for a mammogram. You say that you disagree with the 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 $100 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $100 copayment for a mammogram. This item/service falls within the in-
network 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. However, since the allowed amount is 
less than the standard copayment, you only owe $93.14. Therefore, we decided that the Plan does not have to 
waive the copayment for a mammogram provided on July 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an office visit provided on June 14, 2023. 
 
You asked the Plan to reduce the coinsurance for an office visit. You say that you thought that the provider was 
in-network. 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 50% 
coinsurance for each out-of-network Medicare-covered specialist office visit. 
 
You have been asked to pay 50% coinsurance for an office visit. This item/service falls within the each out-of-
network Medicare-covered specialist office visit 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 total you owe is $77.21 because the Plan is only holding you responsible for this amount which is less than the 50% coinsurance. Therefore, we decided that the Plan does 
not have to reduce the coinsurance for an office visit provided on June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for smoking and tobacco use cessation counseling services 
provided on January 21, 2023. 
 
You asked the Plan to pay for smoking and tobacco use cessation counseling services. The Plan denied your 
request. The Plan says the records do not show that any tobacco cessation counseling occurred. In addition, the 
claim was not submitted with an applicable diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that smoking and tobacco use cessation counseling 
services are covered when the criteria listed in the Medicare rules section of this decision are met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of smoking and tobacco use cessation counseling services have not been met. Therefore, we decided 
that the Plan does not have to pay for smoking and tobacco use cessation counseling services provided on 
January 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete denture  maxillary (D5110) provided on August 
29, 2023. 
 
You asked the Plan to pay for dental services. You say that you thought the service would be covered or at least 
partially covered. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for complete 
denture  maxillary (D5110) provided on August 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the laboratory services provided on August 
3, 2023. 
 
You asked the Plan to waive the deductible for the lab services. You say that you assumed the lab services 
would be fully covered, as they had been 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. Your 
contract with the Plan says that there is a $525 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
 
 You have been asked to pay $188.19 towards your $525 deductible for the lab services. The item or service you 
asked the Plan to waive the deductible for falls within the outpatient diagnostic tests and therapeutic services 
and supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $525 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 lab services was received on 
August 3, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory 
services provided on August 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for transitional care management services 
provided on June 07, 2023. 
 
You asked the Plan to waive the copayment for transitional care management services. You say that you do not 
want to pay for these services. 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 $150 
copayment for Medicare-covered non-surgical outpatient hospital services. 
 
You have been asked to pay a $150 copayment for transitional care management services. This item/service 
falls within the Medicare-covered non-surgical outpatient hospital 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. However, the Plan is only holding you 
responsible for a $57.98 copayment which is less than the $150 copayment. Therefore, we decided that the Plan 
does not have to waive the copayment for transitional care management services provided on June 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for miscellaneous surgical supplies (A4649) provided on June 
14, 2023. 
 
You asked the Plan to pay for surgical supplies. You say that the items at issue were a necessity for your care. 
The Plan denied your request. The Plan says rules for payment for durable medical equipment have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for miscellaneous surgical supplies (A4649) provided on June 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator provided on April 13, 2023. 
 
You asked the Plan to pay for the oxygen concentrator. You say that you were told you would be reimbursed 
for the oxygen concentrator. The Plan denied your request. The Plan says you obtained the item from a 
provider who is not certified with Medicare. 
 
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 oxygen concentrator provided on 
April 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
February 23, 2023, and billed with codes 87798, 87798, 87500, 87640, 87652, and 87481. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on February 23, 2023, and billed with codes 87798, 87798, 87500, 87640, 87652, and 87481.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood glucose monitoring device billed with code 82962 
for March 1, 2023, to March 31, 2023. 
 
You asked the Plan to pay for these services. You say that the claim should be reprocessed. The Plan denied 
your request. The Plan says the claim was processed correctly. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the glucose testing and device was used while the enrollee was inpatient at a SNF. 
Therefore, we decided that the Plan does not have to pay for the blood glucose monitoring device billed with 
code 82962 for March 1, 2023, to March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the clinic services rendered on July 20, 2023, to July 25, 
2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were related to the prior inpatient admission and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic services (including non-patient 
laboratory tests) provided to a Medicare beneficiary by a hospital (or an entity wholly owned or wholly 
operated by the hospital) on the date of the beneficiarys inpatient admission or during the 3 calendar days 
immediately preceding the date of admission are required to be included on the Part A bill for the inpatient 
stay. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were provided within 3 calendar days of the enrollee's inpatient admission and are therefore included in the billing for the inpatient 
stay. Therefore, we decided that the Plan does not have to pay for the clinic services rendered on July 20, 2023, 
to July 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (U0005, G2023, 99072, U0003) provided on 
March 29, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service was out-of-network and non-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 lab testing (U0005, G2023, 99072, U0003) 
provided on March 29, 2023, by an out-of-network (OON) provider.