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

 
We decided that the Plan does not have to waive the $150 copayment charged for outpatient services provided 
on June 24, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment was charged based on the services provided and the 
Plan contract agreement. 
 
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 $150 
copayment for outpatient hospital services. 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 $150 copayment charged for outpatient 
services provided on June 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for glasses provided on May 28, 2020. 
 
You asked the Plan to pay for the glasses. You say that you would like reconsideration because this is a 
covered benefit. The Plan denied your request. The Plan says your benefits were applied correctly. 
 
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 covers one purchase of routine vision hardware every 2 years. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the glasses have not been met. The record indicates that the Plan has processed and paid for other 
routine vision hardware. The Plan covers one purchase which means that your benefit limit has been exhausted. 
Therefore, we decided that the Plan does not have to pay for glasses provided on May 28, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the esophagogastroduodenoscopy and colonoscopy provided 
on November 22, 2019 by an OON provider. 
 
You asked the Plan to pay for the esophagogastroduodenoscopy and colonoscopy. You say that this enrollee 
does not require authorization for the services provided. The Plan denied your request. The Plan says these 
services were rendered by an OON provider. The Plan also says these services were not authorized by 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 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 esophagogastroduodenoscopy and 
colonoscopy provided on November 22, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional facet joint nerve ablation provided on February 
17, 2020, billed with CPT code 64634-RT-59. 
 
You asked the Plan to pay for the billed nerve ablation procedure. You say that this should be paid. The Plan 
denied your request. The Plan says there is no documentation to support another level of this procedure. 
 
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 asked our coding 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 billed nerve ablation procedure. Our 
reviewer says that the billed code is not supported by the records. Our coding reviewer found documentation 
submitted was reviewed. Procedure report documents Radiofrequency ablation. Per AMA CPT "Do not report 
6633, 64634, 64635, 64636 for non-thermal facet joint denervation including chemical, low-grade thermal 
energy (<80 degrees Celsius), or any form of pulsed radiofrequency. To appropriately report any of these 
modalities, use 64999.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed nerve ablation procedure have not been met. Therefore, we decided 
that the Plan does not have to pay for the additional facet joint nerve ablation provided on February 17, 2020, 
billed with CPT code 64634-RT-59.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on June 8, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you have a dual plan. 
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 
emergency care/in-network for emergency care/in-network/emergency services.  
 
You have been asked to pay emergency care/in-network for an emergency room visit. an emergency room visit 
falls within the emergency care/in-network/emergency 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 an emergency room visit provided by a participating provider on June 8, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an OON 
provider. 
 
You asked the Plan to pay for the catheter balloon dilatation, Onabotulinumtoxina injection, 
esophagogastroduodenoscopy, and esophagogastroduodenoscopy injection provided. You 
say that these services were medically necessary. The Plan denied your request. The Plan says the treating 
provider is a non-participating provider with the enrollee's plan. The Plan also says that prior authorization was 
not obtained. 
 
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 OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone density scan billed for date of service June 1, 2020. 
 
You asked the Plan to pay for the bone density scan. You say that the records provided support that multiple 
procedures were rendered on the date of service billed. The Plan denied your request. The Plan says the 
submitted documentation supports one unit of 77080, which was approved and previously paid. 
 
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 documentation shows that the Plan paid for a bone density scan 
provided on June 1, 2020. The medical records provided do not show that an additional imaging study was 
performed on the date of service in dispute or explain why a duplicate study would have been needed. 
Therefore, we decided that the Plan does not have to pay for a bone density scan billed for date of service June 
1, 2020.
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to pay for the nerve conduction. We decided that the Plan does not have to pay for the electroencephalogram.
You asked the Plan to pay for the nerve conduction studies and electroencephalogram. You say that you would like reconsideration based on the records submitted. The Plan says that the documentation submitted does not support the service billed.
We decided that the Plan has to pay for the nerve conduction studies.
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Procedures should be reported with the CPT code that describes the services performed. We asked our coder 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 nerve conduction studies. Our reviewer says that CPT code 95908 meets criteria for billing and reimbursement consideration. The technical report includes the nerve conduction studies.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the nerve conduction studies have been met. Therefore, we decided that the Plan has to pay for the nerve conduction studies.
We also decided that the Plan does not have to pay for the electroencephalogram.
We asked our coder 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 electroencephalogram. Our reviewer found CPT code 95955 does not meet criteria for billing or reimbursement consideration. The operative report does not include documentation of the electroencephalogram during nonintracranial surgery. CPT 95955 does not cover real time electroencephalogram monitoring. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electroencephalogram have not been met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Vitamin D testing provided on March 19, 2020. 
 
You asked the Plan to pay for lab test. You say that you are requesting payment in full for this claim. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this test is not a 
covered benefit for the diagnoses listed and was performed for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code 82306 is only covered for certain 
specific diagnosis codes. Diagnosis code M75.42 is not among those for which 82306 may be covered. 
 
We looked at the file and Medicare rules. This test was not billed with a covered diagnosis code. Based on this 
information, we decided that Medicare rules for coverage of lab test have not been met. Therefore, we decided 
that the Plan does not have to pay for Vitamin D testing provided on March 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) abdomen and 
pelvis (74178) provided on July 29, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you want to appeal the claim because 
you don't agree with the copay. The copay is so high and the plan is paying less than you and you don't 
understand that. The Plan denied your request. The Plan says the claim processed correctly per the Evidence of 
Coverage. 
 
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 $275 
copayment for each advanced imaging service for outpatient diagnostic tests and therapeutic services and 
supplies.  
 
You have been asked to pay $275 copayment for the CT scan. The CT scan 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 computed tomography (CT) abdomen and pelvis (74178) provided on July 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forphysical therapy services provided on January 28, 2020, and March 2, 2020.You asked the Plan to waive the copayment forphysical therapy services. You say that the hospital is billing you incorrectly and you do not remember receiving these services.The Plan denied your request.The Plan says the claims were 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 physical therapy services provided on January 28, 2020, and March 2, 2020. You are asked to pay a $15 copayment per date of service for the physical therapy services. Your EOC states that enrollees must pay a $15 copayment forMedicare-covered Physical Therapy and/or Speech and Language Therapy visits. 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 forphysical therapy services provided on January 28, 2020, and March 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positron emission tomography (PET) scan 
 
You asked the Plan to pay for a PET scan. You say that this should be covered. The Plan denied your request. 
The Plan says this was not billed with an appropriate diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans must be billed with an appropriate 
diagnosis code.  
 
We looked at the file and Medicare rules. The billed diagnosis code, C83.10, is not listed as an appropriate 
code. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met. 
Therefore, we decided that the Plan does not have to pay for a positron emission tomography (PET) scan
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent 
deep vein thrombosis. The Plan denied your request. The Plan says PCDs billed by E0675 are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0675, E0673).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $50 copayment for urgent care services provided on March 3, 2020.
You asked the Plan to waive this copayment. You say that they turned you away and did not treat you. The Plan denied your request. The Plan says medical records were provided to show you received treatment.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $50 copayment for urgent care services. 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 $50 copayment for urgent care services provided on March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composites provided on February 18, 2020. 
 
You asked the Plan to pay for the resin-based composites. You say that the dentist shows as an in-network 
participating provider with your insurance plan. The Plan denied your request. The Plan says services provided 
by a non-participating provider are not covered benefits. 
 
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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-
based composites provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for 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 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 out of network physician 
services provided to the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on February 21, 2020.
You asked the Plan to pay for these services. You say that the Plan denied your request. The Plan says procedure codes 63709 and 63710 are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 63709 and 63047. Code 63709 is a column II code with a modifier indicator of 1 when billed with column I code 63047. Code 63709 was not billed with an appropriate modifier to allow for separate payment. The provider submitted a claim for procedure codes 63710 and 63047. Code 63710 is a column II code with a modifier indicator of 1 when billed with column I code 63047. Code 63710 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the forty-five (45) minute psychotherapy (90836) and the 
twenty-five (25) minute office outpatient visit (99214) provided on April 22, 2020 to June 12, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for office visit and psychotherapy. You say that prior authorization is not required 
for telehealth. 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 forty-five (45) minute psychotherapy (90836) 
and the twenty-five (25) minute office outpatient visit (99214) provided on April 22, 2020 to June 12, 2020 by 
an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) of the 
spine (72148). 
 
You asked the Plan to waive the copayment for the magnetic resonance imaging (MRI) of the spine. You say 
that the MRI was not completed so the copay should be waived. 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 $150 
copayment for high-tech radiology.  
 
You have been asked to pay a $150 copayment for the magnetic resonance imaging (MRI) of the spine. The 
magnetic resonance imaging (MRI) of the spine falls within the high-tech radiology 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 magnetic resonance imaging (MRI) of the spine (72148).