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

 
We decided that the Plan does not have to waive the coinsurance for a diagnostic test provided by a 
participating provider on June 3, 2020. 
 
You asked the Plan to waive the coinsurance for a diagnostic test. You say that you were home and the doctor 
told you to push on button on your pacemaker machine in your bedroom. The Plan denied your request. The 
Plan says the correct coinsurance has been 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 20% 
coinsurance for outpatient diagnostic tests/other outpatient diagnostic tests.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for a diagnostic test. The total allowed 
amount is $39.45. The total amount you are being asked to pay is $7.89 ($39.45 x 20% = $7.89). A diagnostic 
test falls within the outpatient diagnostic tests/other outpatient diagnostic tests 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 coinsurance for a diagnostic test provided by a participating provider on June 3, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on March 
16, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the office called for the 
ambulance but your spouse could have driven you. The Plan denied your request. The Plan says you were 
charged this cost sharing 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 each ambulance trip. You had one ambulance trip. The Plan charged you $300 for these 
services. 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 services provided on March 16, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit charge (coded 99213-25) for services 
provided on November 26, 2019 along with the change of a bladder tube (coded 51705) 
 
You asked the Plan to pay for the office visit charge. You say that the records clearly demonstrate that a 
significant, identifiable service was performed on this date. The Plan denied your request. The Plan says 
criteria for payment of the evaluation and management service have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that visits by the same physician on the same day as a 
minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately 
identifiable service is also performed. 
 
We looked at the file and Medicare rules. The record shows that this visit was primarily for the changing of a 
clogged cystostomy tube. There is no evidence of a separate, identifiable service being provided. No full 
physical exam is documented nor any assessment other than that related to the changing of the tube. Based on 
this information, we decided that Medicare rules for coverage of the office visit charge have not been met. 
Therefore, we decided that the Plan does not have to pay for the office visit charge (coded 99213-25) for 
services provided on November 26, 2019 along with the change of a bladder tube (coded 51705)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chemodenervation of muscle (64615) rendered by the out 
of network (OON) provider on February 28, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 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. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the chemodenervation of muscle (64615) rendered by the out of network (OON) provider on 
February 28, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the head and neck (76536) provided on 
August 24, 2018. 
 
You asked the Plan to pay for the ultrasound. You say that you would like reconsideration because this service 
was denied as a duplicate in error. The Plan denied your request. The Plan says the submitted documentation 
supports one unit of 76563 which was approved and previously 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. 
 
In this case, the CPT Code Manual definition of code 76536 is ultrasound, soft tissues of head and neck (eg, 
thyroid, parathyroid, parotid), real time with image documentation.  
 
We find that CPT code 76536 is not supported in the record. Specifically, the record supports one unit of 
76563. The documentation submitted shows that one unit of CPT code 76536 has been processed and paid. 
There is insufficient information to support an additional ultrasound rendered on the billed date of service. 
Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. 
Therefore, we decided that the Plan does not have to pay for the ultrasound of the head and neck (76536) 
provided on August 24, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased on February 28, 2020 from an 
out-of-network provider. 
 
You asked the Plan to pay for the hearing aids. You say that the hearing aids have helped your quality of life. 
You state you called the Plan to received information. The Plan denied your request. The Plan says this 
provider is not in-network and you chose this provider on your own. The Plan states you called the Plan after 
the services had already been rendered. 
 
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. 
 
Review of the file show that you purchased hearing aids on February 28, 2020 from an out-of-network 
provider. Your EOC states that services are covered only when rendered by a Participating Provider. 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 hearing aids purchased on February 28, 2020 
from an out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on May 11, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
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 psychotherapy services provided on May 11, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic office visit (99202) provided on May 1, 2020 
to May 6, 2020. 
 
You asked the Plan to pay for a chiropractic office visit. You say that you were told you would only have a $20 
copayment. The Plan denied your request. The Plan says your copayment only applies to manipulation services 
and office visits/evaluations are not covered. 
 
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 a chiropractic office visit (99202) provided on May 1, 2020 to May 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urinary catheters (A4353), external catheters (A4349), and 
gloves (A4927) provided on October 5, 2019. 
 
You asked the Plan to pay for catheters and gloves. You say that these items are supported by the records. The 
Plan denied your request. The Plan says the records do not contain a proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. A proof of delivery 
has not been submitted.The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for urinary catheters 
(A4353), external catheters (A4349), and gloves (A4927) provided on October 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 11, 2020. 
 
You asked the Plan to pay for the physician's 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 
physician?s 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 physician's services provided on June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray provided on June 16, 2020. 
 
You asked the Plan to pay for the panoramic x-ray. You say that they had to do a full mouth x-ray to see what 
kind of partial was needed. You say that you thought the x-ray would be covered. The Plan denied your 
request. The Plan says panoramic x-rays are limited to one per 36 months. 
 
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, you also have a maximum benefit of 
one panoramic x-ray every 36 months. The Plan paid for a panoramic x-ray provided on March 14, 2019, 
which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray 
provided on June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 19, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for dermatology services. You say that you are appealing. 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 you could have been treated by an in-network specialist. 
 
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 on February 19, 
2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen (E0443) rendered by the out of network 
(OON) provider on April 29, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 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. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the portable oxygen (E0443) rendered by the out of network (OON) provider on April 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalograms (95955 and 95813) provided on April 
8, 2019. 
 
You asked the Plan to pay for electroencephalograms. You say that these codes are supported by the records. 
The Plan denied your request. The Plan says these codes are 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 95955 is electroencephalogram (EEG) during 
nonintracranial surgery (eg, carotid surgery) and 95813 is electroencephalogram (EEG) extended monitoring; 
greater than 1 hour. 
 
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 electroencephalograms. Our reviewer says 
that the codes are not supported in the medical records. Our physician reviewer found the technical report did 
not include documentation of sensor placement on patient's head and documentation of the procedure being 
performed during surgery to the brain. The technical report also did on include documentation of an EEG 
extended monitoring time of 61-119 minutes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electroencephalograms have not been met. Therefore, we decided that the Plan 
does not have to pay for electroencephalograms (95955 and 95813) provided on April 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lower back brace and the hip brace with a pelvic control 
component provided on April 23, 2020. 
 
You asked the Plan to pay for the back brace and hip brace. You say that the records support that all of these 
braces were necessary and delivered. The Plan denied your request. The Plan says the neck brace was approved 
based on the records but there is no evidence of the need for the other braces. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery. The rules also define the covered indications for a lower back brace. 
 
The file does not include any order for a hip brace or any notation in the medical record regarding the intent to 
provided such a brace. While there is an order form for a lower back brace, review of the progress note does 
not include any information to show that an examination of the back was done or that any of the covered 
indications for a back brace were present. Based on this information, we find that the coverage criteria for these 
items have not been met.  
 
Therefore, we decided that the Plan does not have to pay for the lower back brace and the hip brace with a 
pelvic control component provided on April 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on April 27, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you were told ambulance trips 
were covered. The Plan denied your request. The Plan says the correct copayment has been 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 $250 
copayment for ambulance services/ground travel.  
 
You have been asked to pay a $250 copayment for an ambulance trip. An ambulance trip falls within the 
ambulance services/ground travel 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 ambulance trip provided by a participating provider on April 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses (S0500). 
 
You asked the Plan to pay for the contact lenses. You say that the lenses should be covered. The Plan denied 
your request. The Plan says vision services received out-of-network are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover vision items received out-of-network. 
 
We looked at the file and the Plan's rules. The contact lenses were received from an out-of-network provider. 
Based on this information, we decided that the Plan's rules for coverage of the contact lenses have not been 
met. Therefore, we decided that the Plan does not have to pay for contact lenses (S0500).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 3, 2019. 
 
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 a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physician?s intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on October 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections (J7325) provided May 28, 2020. 
 
You asked the Plan to waive the coinsurance for the injections. You say that the injection did not help, so the 
coinsurance should be waived. The Plan denied your request. The Plan says the correct cost-sharing was 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay a 20% coinsurance for the injections. The injections fall within the Part B 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. 
Therefore, we decided that the Plan does not have to waive the coinsurance for injections (J7325) provided 
May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on February 14, 2020. 
 
You asked the Plan to pay for the acupuncture services. The Plan denied your request. The Plan says your 
health plan benefit package requires the use of in-network providers other than in urgent or emergent situations. 
 
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 
acupuncture 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 acupuncture services provided on February 14, 2020.