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

 
We decided that the Plan does not have to reduce the copayments for the specialist office visits provided from 
March 16, 2020 to May 6, 2020. 
 
You asked the Plan to reduce the copayments for the specialist office visits. You say that the provider is in-
network and you are being overcharged. You say you should only pay a $30 or $35 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 $65 
copayment for provider and professional services at an out-of-network specialist's office.  
 
You have been asked to pay a $65 copayment for each of the specialist office visits. ($65 x 4 visits = $260). 
The specialist office visits fall 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 reduce the copayments for the specialist office visits 
provided from March 16, 2020 to May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit services provided on March 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the office visit 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 provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit services provided on March 18, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services you received from September 20, 2019, to 
September 23, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you are responsible for 
the charges. 
 
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 each day of observation care at an outpatient hospital.  
 
Review of the file shows that you were provided three days of observation care from September 20, 2019, to 
September 23, 2019. Per the Plan contract, you are responsible for a $350 copayment per day for these 
services. However, the Plan has assessed a copayment of $379.12, therefore you have been asked to pay the 
lesser amount. 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 rules also 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 services you received from September 20, 2019, to 
September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on March 6, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received office visit services beyond the scope of your annual wellness visit. 
The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 
copayment for each primary care visit.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows you received office visit services 
beyond the scope of your annual wellness visit on March 6, 2020. You have been asked to pay a $20 
copayment for the office visit. The office visit falls within the Physicians/Practitioners 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 office visit provided on March 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 1, 2020. 
 
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. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services provided on February 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (01380, 76942) provided on September 5, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these are duplicate 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.  
 
We looked at the file and Medicare rules. The records show that the services in question were billed on a 
duplicate claim to one previously processed by the Plan. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for the services (01380, 76942) provided on September 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray (71045) performed March 4, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that the service was medically necessary. The Plan 
denied your request. The Plan says code 71045 shares a column I/II relationship with another code billed on the 
same service date. 
 
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 71045 
has a Column I / Column II relationship with code 32555 which was already paid. The required modifier to 
denote a distinct service was not included. This code cannot be paid as a separate line item. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for a chest x-ray (71045) performed March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (01992) provided on March 13, 2020. 
 
You asked the Plan to pay for the anesthesia services (01992). You say that the anesthesia services provided 
were medically necessary. The Plan denied your request. The Plan says the anesthesia services provided were 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 pay for the anesthesia services (01992). Our 
reviewer says that the anesthesia services provided were not medically necessary. Our physician reviewer 
found this enrollee had a transforminal epidural steroid injection performed with IV sedation provided by an 
anesthesiologist. The enrollee is not morbidly obese, does not have Obstructive sleep apnea, a history of drug 
abuse, nor of mental infirmity.  
 
There was no indication for intravenous sedation. The ASA committee on Pain has specifically stated that it is 
not usually necessary to provide sedation for an epidural. Therefore, the anesthesia procedure was not 
medically reasonable or 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 anesthesia services (01992) have not been met. Therefore, we decided that 
the Plan does not have to pay for the anesthesia services (01992) provided on March 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture. 
 
You asked the Plan to pre-approve the dentures. You say that you have been having difficulties and pain when 
eating. The Plan denied your request. The Plan says although there may be a need for a new denture, it is not 
covered at this time. 
 
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. The Plan covers dentures once 
every five years. 
 
You last received dentures in December 2019. They are only covered once every five years. Based on this 
information, we decided that the Plan's rules for coverage of the dentures have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a complete maxillary denture.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve section assisted lipectomy and tissue transfer surgery. 
 
You asked the Plan to pre-approve plastic surgery services. You say that you are in pain and cannot put on a 
bra or put your arms down without being in pain. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because these services are cosmetic in nature and are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 plastic surgery services. Our reviewer 
says that you do not meet the Medicare criteria for the requested surgical services. Our reviewer found the 
requested treatment plan is consistent with treatment of your stated aesthetic concerns. There is insufficient 
medical documentation that the surgical plan requested is for treatment of a functional impairment or other 
reconstructive surgery. You do have a medical complication which has an apparent functional impairment; 
however, the documentation does not support that the planned surgical treatment would address this 
impairment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of plastic surgery services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve section assisted lipectomy and tissue transfer surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 29823 provided on November 21, 2019. 
 
You asked the Plan to pay for CPT code 29823. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the medical records do not support the billing of CPT 
code 29823. 
 
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, the CPT Code Manual definition of code 29823 is Arthroscopy, shoulder, surgical; debridement, 
extensive. 
 
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 pay for CPT code 29823. Our reviewer says that the 
medical records do not support the billing of CPT code 29823. Our physician reviewer found based on the 
documents provided, the medical records do not support the billing of CPT code 29823. The medical records 
provided do not include documentation to validate that an Arthroscopy, shoulder, surgical; debridement, 
extensive was performed on November 21, 2019. Per the National Correct Coding Initiative Policy Manual for 
Medicare Services, Revision Date: 1/1/2019; in regards to the submitted (CPT) code of 29823, the patient is 
positioned side-lying with arm suspended using a weight and a pulley system. An anesthetic is administered. 
Small percutaneous poke hole (port) incisions are made around the shoulder joint to allow access to all areas of 
the shoulder joint. A solution is pumped through one of these incisions and into the joint to expand the joint for 
better visualization and to cleanse the joint. The arthroscope is inserted allowing the physician to perform a 
diagnostic arthroscopic exam by visualizing the shoulder joint. A long-acting local anesthetic may be injected 
into the joint to help with postoperative pain. The joint is irrigated and suture, band aid, or Steri-strips close the 
incisions. The area is covered with a dressing and a sling or shoulder immobilizer is applied. Report 29822 if 
the arthroscopic surgery is performed with limited debridement and 29823 if the procedure includes extensive 
debridement. When arthroscopy is performed in conjunction with arthrotomy, add modifier 51. Surgical 
arthroscopy always includes diagnostic arthroscopy. According to CPT guidelines, cast application or strapping 
(including removal) is only reported as a replacement procedure or when the cast application or strapping is an 
initial service performed without a restorative treatment or procedure. This description was not documented in 
the operative note, therefore this service cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPT code 29823 have not been met. Therefore, we decided that the Plan does 
not have to pay for CPT code 29823 provided on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic consultation (99204) to be provided by an 
out of network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to provide this 
service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an 
orthopedic consultation (99204) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spinal injection provided on May 12, 2020.

You asked the Plan to waive the copayment for the spinal injection. You say that you should not be responsible for the $210 copayment because it was a simple procedure. You say it appears your share is based on the building and not the procedure. 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 $210 copayment for each Medicare-covered outpatient admission to an ambulatory surgical center. 

You have been asked to pay a $210 copayment for the spinal injection. The spinal injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows that the spinal injection is considered a surgical procedure at an ambulatory surgical center.

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 spinal injection provided on May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient radiological services and specialist visits provided from February 25, 2020 to March 2, 2020.
You asked the Plan to waive the copayments for the outpatient radiological services and specialist visits. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient radiological services and specialist visits on the dates of service at issue in this appeal. The Plan says that the correct cost share has applied per your contract with the Plan.
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 $125 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility and a $40 copayment for services obtained from a specialist. We looked at the file, the Plan's contract and Medicare rules. The file shows you received outpatient radiological services on February 25, 2020 and February 27, 2020. You have been asked to pay a $125 copayment for each outpatient radiological service. The outpatient radiological services fall within the Outpatient diagnostic tests benefit category. The file also shows you received services provided by a specialist on February 28, 2020 and March 2, 2020. You have been asked to pay a $40 copayment for each specialist visit. The specialist visits fall within the Physicians/Practitioner services benefit category. This means that you have been asked to pay the correct amounts 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 outpatient radiological services and specialist visits provided from February 25, 2020 to March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided to the enrollee on November 7, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there are in-network contracted providers available who could have provided 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 has network providers 
available who can provide 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 to the enrollee on 
November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided to the enrollee on November 
11, 2019. 
 
You asked the Plan to pay for the services. You say that the clinical notes should be reviewed for medical 
necessity. The Plan denied your request. The Plan says treatment available for chiropractic care coverage is 
manual manipulation of the spine to correct a subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services provided to the enrollee on November 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was transported twice on the 
date of service. You stated that one of the transports was covered by the Plan but the other was denied. You say 
that the Plan should cover both transports and you asked the Plan to reconsider their denial. 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 pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor?s office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctor?s office. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.