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

 
We decided that the Plan does not have to waive the cost-share for the services provided on December 17, 2019 
and December 24, 2019 at the outpatient department of the in-network provider. 
 
You asked the Plan to waive the cost-share for the services. You say that you asked the provider is Medicare 
would cover this and they said yes. The Plan denied your request. The Plan says the claims were processed 
accordingly with your 2019 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received injection, ferric carboxymaltose, 1 mg (CPT Code J1439) and 
outpatient services provided on on December 17, 2019 and December 24, 2019 at the outpatient department of 
the in-network provider. You are asked to pay a $150 copayment per date of service for the services provided 
at the outpatient department. Furthermore, the allowed amount for your injection was $811.80 per visit. You 
have been asked to pay a $162.36 coinsurance for the injection each visit ($811.80 x 20% = $162.36). Your 
EOC states that enrollees must pay 20% coinsurance for in-network chemotherapy drugs, infusion drugs, and 
all other drugs covered under Medicare Part B and enrollees must pay a $150 copayment for all other services 
performed at an in-network Outpatient Facility not otherwise noted. 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 
cost-share for the services provided on December 17, 2019 and December 24, 2019 at the outpatient 
department of the in-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90834) provided April 17, 
2020 to May 1, 2020. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services should be 
covered and were denied in error. The Plan denied your request. The Plan says the provider at issue is not 
eligible for Medicare payment. 
 
The Plan must follow Medicare rules. Medicare rules say that Licensed Professional Counselors (LPC?s) are 
not eligible for enrollment in the Medicare program.  
 
We looked at the file and Medicare rules. The services were provided by a Licensed Professional Counselor. 
This type of provider is not eligible for Medicare payment. Based on this information, we decided that 
Medicare rules for coverage of the outpatient mental health services have not been met. Therefore, we decided 
that the Plan does not have to pay for outpatient mental health services (90834) provided April 17, 2020 to May 
1, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the femtosecond laser assisted cataract surgery with 
astigmatic keratotomy provided on February 19, 2020. 
 
You asked the Plan to reimburse for the femtosecond laser assisted cataract surgery with astigmatic 
keratotomy. You say that you would like the Plan to reconsider your request. The Plan denied your request. 
The Plan says they paid for the Medicare-covered traditional portion of the enrollee's cataract surgery. The Plan 
says that the laser cataract surgery with astigmatism reduction is not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare coverage and payment for cataract surgery is the 
same regardless if the surgery is performed using conventional surgical techniques or a bladeless, computer 
controlled laser. 
 
Under either method, Medicare will only pay for the cataract removal and insertion of a conventional 
intraocular lens. In this case, the plan has paid for the extracapsular cataract removal with insertion of 
intraocular lens procedure; however, neither Medicare nor the plan is responsible for any charges over the 
cataract removal and insertion of intraocular lens portion of the procedure. Therefore, we decided that the Plan 
does not have to reimburse for the femtosecond laser assisted cataract surgery with astigmatic keratotomy 
provided on February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 18, 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 providers must report services correctly. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in POS 20. 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 November 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided from December 19, 2019 to 
December 22, 2019. 
 
You asked the Plan to pay for inpatient care. You say that these services were medically necessary. The Plan 
denied your request. The Plan says this was not authorized and the enrollee was stable upon admission. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient care. Our reviewer says that the 
criteria for coverage of these services has not been met. Our physician reviewer found the patient appeared to 
be stable for transfer at the time of admission and the treating physicians did not document that the patient was 
not stable for transfer at any time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient care provided from December 19, 2019 to December 22, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit evaluation service provided on September 19, 2019.

You asked the Plan to pay for the home visit for the evaluation and management of an established patient. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the medical records show the services were performed by an LVN.

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 99350 is Home visit for the evaluation and management of an established patient.

We find that CPT code 99350 is not supported in the medical record. Specifically, the physician was not present in the residence. Based on this information, we decided that Medicare rules for coverage of the home visit for the evaluation and management of an established patient have not been met. Therefore, we decided that the Plan does not have to pay for the home visit evaluation service (99350) provided on September 19, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99348) provided on September 3, 2019. 
 
You asked the Plan to pay for the home visit. You say that you would like reconsideration because the services 
rendered were medically necessary. The Plan denied your request. The Plan says the billed code does not 
appropriately reflect the services provided. 
 
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 99348 is home visit for the evaluation and management 
of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused 
interval history; An expanded problem focused examination; Medical decision making of low complexity. 
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face 
with the patient and/or family.  
 
We find that CPT code 99348 is not supported in the record. Specifically, the documentation submitted 
indicates that this service was rendered by a licensed vocational nurse. There is no indication that the physician 
was present at the time this service was performed. Based on this information, we decided that Medicare rules 
for coverage of the home visit have not been met. Therefore, we decided that the Plan does not have to pay for 
the home visit (99348) provided on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
February 19, 2020 by  an in-network provider. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you are appealing your 
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim 
was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received the specialist office services provided on February 19, 2020 by an in-
network provider. You were asked to pay a $50 copayment for the specialist services. Your EOC states that 
enrollees must pay a $50 copayment for each in-network specialist visit for Medicare-covered 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 specialist office visit provided on February 19, 2020 by  
an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit rendered on August 29, 2019. 
 
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 procedure code 99348 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 99348 is home visit for the evaluation and management 
of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused 
interval history; An expanded problem focused examination; Medical decision making of low complexity. 
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face 
with the patient and/or family.  
 
We find that CPT code 99348 is not supported in the medical record. Specifically, the records show that the 
services were not performed by a physician or advanced practitioner. The services were performed by a LVN, 
which does not meet the criteria for the code. 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 for the 
home visit rendered on August 29, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 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 June 6, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 13, 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 June 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic eye exam (92014) provided on 
September 24, 2019. 
 
You asked the Plan to waive the copayment for a diagnostic eye exam. You say that this should have been fully 
covered. The Plan denied your request. The Plan says this processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for Medicare-covered eye exams.  
 
You have been asked to pay a $40 copayment for a diagnostic eye exam. 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 eye exam (92014) provided on September 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crowns for tooth #'s 22 to 27 on January 29, 2020. 
 
You asked the Plan to pay for the crowns. You say that you needed emergency dental services. You say that the 
services should be covered. The Plan denied your request. The Plan says your plan does not cover services 
billed by providers outside of the United States and its territories. 
 
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, foreign dental services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for crowns for tooth 
#'s 22 to 27 on January 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen concentrator (CPT Code E1390) provided on March 
22, 2020 by an out-of-network provider. 
 
You asked the Plan to pay for the oxygen concentrator. You say that the enrollee has been on service with this 
provider prior to the health plan change and did not notify your company of any changes. You state the enrollee 
had been receiving routine maintenance/servicing of the durable medical equipment (DME) through the 
company due to the enrollee not being redirected to an in-network provider by the primary care physician or 
health plan. The Plan denied your request. The Plan says sufficient information was not provided from the 
provider as evidenced by a lack of recent oximetry test, or updates on the status of the oxygen (O2) therapy 
use. Pulse Ox report June 22, 2009. The Plan states no prior authorization is on file and they approved an 
alternative in-network DME provider. 
 
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 oxygen concentrator. Our physician 
reviewer found the coverage criteria for home oxygen are not met.  
 
 
The overnight oximetry data showing need for oxygen is from 2009. Current/more recent assessment of clinical 
status and oxygenation are needed to qualify for continued oxygen coverage. Otherwise, home oxygen is 
considered not medically necessary, and the denial is upheld. 
 
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 oxygen concentrator have not been met. Therefore, we decided that the Plan 
does not have to pay for oxygen concentrator (CPT Code E1390) provided on March 22, 2020 by an out-of-
network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 30, 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 May 30, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory testing provided on January 27, 
2020. 
 
You asked the Plan to waive the copayment for lab test. You say that you thought you only had to pay 1 
laboratory copayment per day. The Plan denied your request. The Plan says the copayment amount you are 
being charged is correct. 
 
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 $10 
copayment for lab services, per day per provider. This lab testing was performed by a separate lab provider; 
therefore, a separate lab copayment applies to this claim. 
 
You have been asked to pay $10 copayment for lab test. Lab test falls within the 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. Therefore, we decided that the Plan does not have to waive the copayment 
for laboratory testing provided on January 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on April 
30, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that this was an emergency 
transport. The Plan denied your request. The Plan says that the copayment was 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 $270 
copayment per date of service regardless of the number of ground ambulance trips.  
 
You have been asked to pay a $270 copayment for the ambulance transport. The ambulance transport falls 
within the ground ambulance trips benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the ambulance transport provided on April 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse an additional $50 for the health club membership 
purchased on January 1, 2019. 
 
You asked the Plan to reimburse an additional $50 for the health club membership. You say that you believe 
you are entitled to a fitness reimbursement of $300, not just $250. The Plan denied your request. The Plan says 
you have reached your plans maximum allowance for your 2019 wellness benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
It was determined that you have reached your plans maximum allowance for your 2019 wellness benefit. On 
April 3, 2020 a check was issued in the amount of $250 towards your 2019 wellness allowance. Your EOC 
states that the plan reimburses you up to $250 each calendar year towards your cost for membership in a 
qualified health club or fitness facility and you pay all charges over $250 per calendar year. Therefore, we 
decided that the Plan does not have to reimburse an additional $50 for the health club membership purchased 
on January 1, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on February 18, 2020.
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 procedure code 95999 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 95999 is unlisted neurological or neuromuscular
diagnostic procedure.
We find that CPT code 95999 is not supported in the medical record. Specifically, the file shows that Train of
Four testing was performed and there is a more appropriate code for these services. Based on this information,
we decided that Medicare rules for coverage of these services have not been met. Please note that the Plan
states you will not be responsible for payment of these services. Therefore, we decided that the Plan does not
have to pay for the testing services rendered on February 18, 2020.