Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided. 
 
You asked the Plan to waive the copayment for physical therapy. You say that this provider was the only 
option because every gym was closed. You say that you want the $30 copayment per visit waived. The Plan 
denied your request. The Plan says three copayments were paid by the Plan in error, but the remaining 
copayments applied 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 each Medicare-covered physical therapy and speech-language therapy visit. 
 
You have been asked to pay a $30 copayment for each for physical therapy visit. The total amount you owe is 
$600 ($30/visit x 20 visits = $600). Physical therapy falls within the "Outpatient Rehabilitation Services" 
benefit category. The Plan says that only the cost share for services provided will be waived.  
 
  
 
 
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 physical therapy provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80061, 80053, 84443 and 36415) 
provided on May 22, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the services rendered were medically necessary. 
The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
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 laboratory services (80061, 80053, 84443 and 
36415) provided on May 22, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient surgical services you received 
from an ambulatory surgical center from June 3, 2020, to June 17, 2020. 
 
You asked the Plan to waive the copayments for the surgical services. You say that this cost sharing is a 
hardship for you. The Plan denied your request. The Plan says you were charged these amounts correctly.  The 
Plan says that because the allowed amount for each date of service is less than your copayment obligation, you 
are responsible for the full 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 services in an ambulatory surgical center.  
 
You have been asked to pay a $300 copayment for the surgical services. In this case, on each of the three dates 
of service, the allowed amount for the service is less than this $300 copayment obligation.  That is why your 
Plan charged you the full amount for each date. 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 outpatient 
surgical services you received from an ambulatory surgical center from June 3, 2020, to June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental items. You say that you received a denial for the partial dentures 
stating that you received dentures in 2015. You say that you did not. You say that you only received an 
extraction. The Plan denied your request. The Plan says these items are dental in nature. The Plan also says that 
partial dentures are not covered by Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture 
(D5213) and a partial lower denture (D5214).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 6, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on November 6, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast ultrasound, professional component, provided on 
May 26, 2020. 
 
You asked the Plan to pay for the breast ultrasound, professional component. You say that the Plan should pay 
this claim. The Plan denied your request. The Plan says this claim was already paid. 
 
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 76642 is not supported in the medical record. Specifically, the medical records support 
1 unit, which was paid. Based on this information, we decided that Medicare rules for coverage of the breast 
ultrasound, professional component have not been met. Therefore, we decided that the Plan does not have to 
pay for the breast ultrasound, professional component, provided on May 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for spinal chiropractic manipulative treatment provided. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the services billed by your provider are not covered by Medicare or the 
Plan. 
 
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 spinal 
chiropractic manipulative treatment provided.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on March 9, 2020 
and billed under codes 96132, 96133, 96138, and 96139. 
 
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan says 
code 96132 was denied because the documentation submitted does not include the time spent to support 
Neuropsychological testing evaluation services by physician or other qualified health care professional. The 
Plan says that code 96133 (3 units) was denied because the primary code 96132 was denied, and code 96133 
cannot be billed separately. The Plan states code 96138 (1 unit) was denied because the documentation does 
not include the time spent with the enrollee. In addition, code 96139 remains denied because the primary code 
was denied, and this code cannot be billed separately.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code and the medical record documentation must 
support the services billed. In this case, this claim cannot be paid because the medical records provided do not 
support the services billed. Medicare billing criteria were not met based on the lack of documentation of the 
time requirements for the primary codes billed. Therefore, we decided that the Plan does not have to pay for 
physician services provided to the enrollee on March 9, 2020 and billed under codes 96132, 96133, 96138, and 
96139.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 22, 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 laboratory services are not supported in the medical record. Specifically, the documentation 
submitted did not support that the laboratory testing was performed with blood sampling. The lab requisition 
shows a urine sample was collected. 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 May 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation services. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that you have exhausted the allowable trips for this 
calendar year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 150 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advance care planning (99497) provided on 
 
You asked the Plan to pay for advance care planning. You say that this is supported in the records. The Plan 
denied your request. The Plan says this is not documented. 
 
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 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, 
family member(s), and/or surrogate. 
 
We find that CPT code 99497 is not supported in the medical record. This service is not documented in the 
medical records. Based on this information, we decided that Medicare rules for coverage of advance care 
planning have not been met. Therefore, we decided that the Plan does not have to pay for advance care 
planning (99497) provided on
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve a mandibular partial denture (D5214). You say that you would like the Plan 
to reconsider their denial. The Plan denied your request. The Plan says your record shows you were provided 
partial dentures. The Plan says they contacted your provider and confirmed your dentist can 
assist you with your current dentures. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, partial dentures are only covered once 
every five years. The file shows you received partial dentures, which is less than five years 
ago. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on March 2, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code G0483 is not supported.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 G0483 is definitive drug testing, 22 or more classes.We find that CPT code G0483 is not supported in the medical record. Specifically, there is no lab report for confirmative tests. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered on March 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for intravenous (IV) drugs you received from 
May 14, 2019 to May 15, 2019. 
 
You asked the Plan to waive the coinsurance for the IV drugs. You say that it is ridiculous that more than 14 
months passed before you were billed. The Plan denied your request. The Plan says you were charged this 
coinsurance 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 drugs.  
 
You have been asked to pay 20% coinsurance for the IV drugs. The IV drugs fall within the Medicare Part B 
drugs benefit category. This cost sharing applies regardless of how long it takes the provider to bill you. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for intravenous (IV) drugs you received from May 14, 2019 to 
May 15, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cystoscopy (52000) performed on July 
13, 2020. 
 
You asked the Plan to waive the copayment for a cystoscopy. You say that you should have been told that a 
different cost-share applied due to the change in location of procedure administration The Plan denied your 
request. The Plan says the correct copayment 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 $400 
copayment for same day outpatient surgery in an outpatient hospital facility.  
 
You have been asked to pay a $400 copayment for a cystoscopy. A cystoscopy falls within the "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. Therefore, we decided that the Plan does not have to waive the copayment for a cystoscopy (52000) 
performed on July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transthoracic echocardiography (93306) 
performed on January 29, 2020. 
 
You asked the Plan to waive the copayment for a transthoracic echocardiography. You say that you paid the 
doctor yourself because you had not received your Plan card yet. The Plan denied your request. The Plan says 
the correct copayment 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 $35 
copayment for consultation, diagnosis, and treatment by a specialist.  
 
In this case, the Plan has confirmed with the provider's office that the office is prepared to reimburse you. You 
have therefore been asked to pay a $35 copayment for a transthoracic echocardiography. A transthoracic 
echocardiography falls within the "Physician/Practitioner services, including doctor's office visits" benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a transthoracic echocardiography (93306) 
performed on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided, to by an out of network 
(OON) provider. 
 
You asked the Plan to pay for office services. You say that this provider took your insurance at each visit, and 
if you had known they did not take your insurance you would not have gone to them. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because this provider is out-of-
network with the Plan and prior approval was not given 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 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 medical services provided by an out of 
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye examination provided on October 17, 2019. 
 
You asked the Plan to pay for the eye examination. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan.  
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an eye examination provided on October 17, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy (45380) 
performed on July 23, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that this service should have 
been billed under the emergency services benefit. The Plan denied your request. The Plan says the correct 
copayment 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 $350 
copayment for each in-network visit for outpatient surgery.  
 
In this case, the record reflects that you did not receive the service in dispute in the emergency department. You 
have therefore been asked to pay a $350 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy 
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 a diagnostic 
colonoscopy (45380) performed on July 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the enrollee is not homebound. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that the enrollee is homebound. Therefore, we decided that the Plan does not have to 
pre-approve home health aide services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intubation (31500) provided on January 21, 2020. 
 
You asked the Plan to pay for intubation. You say that this should be covered. The Plan denied your request. 
The Plan says this is not documented. 
 
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 31500 is intubation, endotracheal, emergency procedure. 
 
We find that CPT code 31500 is not supported in the medical record. Specifically, there is no documentation of 
this procedure in the medical records. Based on this information, we decided that Medicare rules for coverage 
of intubation have not been met. Therefore, we decided that the Plan does not have to pay for intubation 
(31500) provided on January 21, 2020.