Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment with CPT code L1833 
provided on May 19, 2020. 
 
You asked the Plan to pay for the durable medical equipment. 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. The rules state that DMEPOS is covered only when the patient?s medical 
record contains sufficient documentation of the patient?s medical condition to substantiate the necessity for the 
type and quantity of items ordered and for the frequency of use.  
 
The record shows that documentation submitted did not indicate the provider discussed the need for the billed 
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to 
pay for the durable medical equipment with CPT code L1833 provided on May 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns (D2740) and core build up (D2950) for teeth # 14 
and 15 provided. 
 
You asked the Plan to pay for the dental services. You say that you were startled when you found out you did 
not have dental insurance. You say that your wife always added it. You say that you found out that your dental 
coverage ended when your wife passed away. You also say that you were advised that your dental coverage 
would be reinstated starting July 2019. The Plan denied your request. The Plan says you were not enrolled in 
the Optional Supplemental Rider on the date of service. The Plan says multiple letters were sent to you to 
inform you of past due premiums and that the Optional Supplemental Rider was to be terminated on September 
30, 2019 due to non-payment of premiums. The Plan also says that you were advised when you called on 
January 14, 2020 to enroll in the Optional Supplemental Rider that it would be effective. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for 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. The record shows that you were not enrolled in the Optional Supplemental Rider on the date 
of service. Therefore, we decided that the Plan does not have to pay for the crowns (D2740) and core build up 
(D2950) for teeth # 14 and 15 provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered from February 25, 2019 to 
February 26, 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 99291 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 
30-74 minutes of critical care services spent on the enrollee. 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 critical care services rendered from February 25, 2019 to February 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99214) 
provided on July 21, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. You say that you would 
like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior 
authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 established patient office or other outpatient 
visit (99214) provided on July 21, 2020, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the travel allowance charge provided. 
 
You asked the Plan to pay for travel allowance charge. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the documentation submitted did not include documentation to support 
travel allowance. 
 
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 P9603 is travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled.  
 
We find that CPT code P9603 is statutorily not covered by Medicare. Based on this information, we decided 
that Medicare rules for coverage of Travel allowance have not been met. Therefore, we decided that the Plan 
does not have to pay for the travel allowance charge provideed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment (E1390, E0431) provided on May 21, 
2020, to June 21, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the oxygen equipment. You say that the items provided were medically 
necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or 
the provider; therefore, payment has been correctly denied. 
 
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 oxygen equipment (E1390, E0431) provided 
on May 21, 2020, to June 21, 2020, by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital surgery rendered on 
December 2, 2019. 
 
You asked the Plan to waive the copayment for these services. You say that you are charged $375 every time 
you go to the doctor. The Plan denied your request. The Plan says 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 $375 
copayment for outpatient hospital surgery.  
 
Review of the file shows that you received outpatient surgical services in the form of a throat exam 
(laryngoscopy) on December 2, 2019. You have been asked to pay a $375 copayment for these services. These 
services fall within the outpatient hospital surgery 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 outpatient hospital surgery rendered on December 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a behavioral health inpatient admission provided from 
February 10, 2020, through February 20, 2020. 
 
You asked the Plan to pay for the behavioral health inpatient admission. The Plan denied your request. The 
Plan says prior authorization was not obtained by the provider or facility. The provider should have verified the 
member's eligibility, health benefits and obtained authorization prior to the member's visit before providing 
services to the member as outlined on the member's ID card. 
 
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 a behavioral health inpatient admission provided from February 
10, 2020, through February 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you should have no 
responsibility because you feel like you were kept in the hospital longer than necessary. The Plan denied your 
request. The Plan says that the claim processed and paid 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 $298 
copayment for per day, days 1 to 7 of Inpatient hospital care.  
 
You have been asked to pay a $298 copayment for the inpatient hospital services. The inpatient hospital 
services fall within the days 1 to 7 of Inpatient hospital care 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 inpatient hospital services provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (84481, 84439, 84443, 80053) 
provided on June 4, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or 
the provider; therefore, payment has been correctly denied. 
 
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 (84481, 84439, 84443, 
80053) provided on June 4, 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 chiropractic services provided  that were not 
related to manual manipulation. 
 
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 services other than manual manipulation 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 chiropractic 
services provided that were not related to manual manipulation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 71045) provided on June 29, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is inclusive 
to CPT 32555. 
 
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, 
the column two code is denied, and the column one code is eligible for payment. Procedure code 71045 is part 
of an edit pair with procedure code 32555. Procedure code 32555 is a column one code, and procedure code 
71045 is a column two code. Procedure code 32555 has been billed and paid for this date of service, which 
means that procedure code 71045 is not eligible for payment. Therefore, we decided that the Plan does not have 
to pay for the services (CPT 71045) provided on June 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for professional attendance and 
supervision of hyperbaric oxygen therapy, provided on December 12, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
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 for professional attendance and 
supervision of hyperbaric oxygen therapy, provided on December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the cost share for the dental services you received. 
 
You asked the Plan to adjust the cost share. You say that you did not received the Plan book. 
The Plan denied your request. The Plan says you are responsible for the cost share. 
 
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% 
coinsurance for out-of-network non-Medicare covered preventive dental services.  
 
Review of the file shows that you were provided non-Medicare covered preventive dental services by an out-
of-network provider. You have been asked to pay a 30% coinsurance for the dental 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 adjust the cost share for the dental services you received.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided to the enrollee on February 
24, 2020 and billed under code 99203. 
 
You asked the Plan to pay for code 99203. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says Physical therapy modalities, X-rays, rehabilitation and other incidental 
services including office evaluation and management by chiropractors are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services provided to the enrollee on February 24, 2020 and billed under codes 99203.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder orthosis (L3660) provided on July 9, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for shoulder orthosis. You say that you do not provide the items to the patient, the 
items are provided to the hospital which provides to the patient. 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 shoulder orthosis (L3660) provided on July 9, 
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 the moderate sedation services rendered on February 14, 
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 99152 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 99152 is moderate sedation services by physician also 
performing a procedure, patient 5 years of age or older, first 15 minutes. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of 
an independent trained observer to assist in monitoring the patient's level of consciousness and physiological 
status. 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 moderate sedation services rendered on 
February 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on April 23, 2020. 
 
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 
the Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 
diagnostic radiology 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 diagnostic radiology services provided on April 
23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that these were follow-up 
visits. 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 $20 
copayment for physician/practitioner services/in-network/specialist.  
 
You have been asked to pay a $20 copayment for each specialist office visit. The total amount you are being 
asked to pay is $40 ($20 x 2 visits = $40). A specialist office visit falls within the physician/practitioner 
services/in-network/specialist 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 specialist 
office visit provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services provided on July 1, 2020. 
 
You asked the Plan to pay for the surgical pathology 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 
surgical pathology 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 surgical pathology services provided on July 1, 
2020.