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

 
We decided that the Plan does not have to pay for the oxygen equipment coded as E1356, E1390, E1399 and 
99999 provided May 25, 2022, to May 31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the oxygen equipment. You say that your husband called the Plan and was told 
that the equipment purchase would be reimbursed up to 80% of the cost. You were not told the purchase of the 
equipment would have to be purchased through a medical supplier. The Plan denied your request. The Plan 
says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being 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. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided 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 coded as E1356, E1390, 
E1399 and 99999 provided May 25, 2022, to May 31, 2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room service provided July 
18, 2022. 
 
You asked the Plan to waive the copayment for an emergency room service. You say that you feel the 
emergency room visit was not worth it. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room service. This item/service falls within the 
emergency 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 an emergency room service 
provided July 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services on July 01, 2022. 
 
You asked the Plan to waive the copayment for outpatient services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $340 
copayment for each Medicare-covered visit to an ambulatory surgical center or outpatient hospital facility. The 
provider billed in the amount of $390 and the allowed is $270.38. This is less than the copayment amount. 
Therefore, results in the total cost sharing amount of $270.38.  
 
 
 
 
 
 You have been asked to pay a $270.38 copayment, which is less than the copayment for outpatient services. 
This item/service falls within the Outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for outpatient services on July 01, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is not an agreement to 
include this in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay 
for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93010 provided on July 11, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for code 93010. You say that you were not aware that prior authorization was 
required. The Plan denied your request. The Plan says unauthorized, out-of-network services are not covered. 
 
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 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 code 93010 provided on July 11, 2022, by an out-of-network 
(OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurology services provided to the enrollee on March 30, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there are no authenticated medical records (e.g. a progress note) from the ordering provider 
documenting the treating physician had intended the clinical diagnostic be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. Despite 
multiple requests from the plan, no medical records have been provided to verify if the denied codes were 
actually rendered in this case. Therefore, we decided that the Plan does not have to pay for neurology services 
provided to the enrollee on March 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy (45381) and 
intravenous (IV) infusion for hydration (96360, 96361) provided on June 14, 2022, and June 15, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy and hydration services. You say that 
you should not have to pay for the services. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $325 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $650 copayment for a diagnostic colonoscopy and hydration services ($325 
copayment  2 services = $650 copayment). These services fall within the outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers benefit category.  This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for a diagnostic colonoscopy (45381) and intravenous (IV) 
infusion for hydration (96360, 96361) provided on June 14, 2022, and June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment of methadone (G2067) and a 
take home supply of methadone (G2078) provided on December 20, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for medication assisted treatment of methadone (G2067) and a take home supply of 
methadone (G2078). You say that that this facility is an opioid treatment program (OTP) clinic. You also say 
that no authorization is required for federally qualified health centers (FQHC) tribal OTP facilities due to the 
patient's not making appointments, but coming in when they decide to seek treatment, per the Centers for 
Medicare and Medicaid Services (CMS). The Plan denied your request. The Plan says the member does not 
have out of network benefits. The Plan also says that the referring provider is a non-contracted provider, as 
well as no indication any attempt was made to obtain prior authorization for the out of network services.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided 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 medication assisted treatment of methadone 
(G2067) and a take home supply of methadone (G2078) provided on December 20, 2021, by an out-of-network 
(OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (90792) provided on March 7, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says Original Medicare is liable for payment for this service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician services (90792) provided on March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided on 
October 1, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment The Plan denied your request. The Plan says that the services at issue are not payable as the 
medical records have not been provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the case file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of these services have been met.  
Therefore, we decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) 
provided on October 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital admission provided on 
August 11, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital admissio. You say that the services 
should be covered as you disagree with the denial. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $295 
copayment for Inpatient hospital care.  
 
 
  You have been asked to pay a $295 copayment for the inpatient hospital admissio. This item/service falls 
within the 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 
an inpatient hospital admission provided on August 11, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on May 5, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they were non-emergent and 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 had network providers 
available who could have provided 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 outpatient mental health services provided on May 
5, 2022, 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 outpatient surgical services provided on 
May 19, 2022. 
 
You asked the Plan to waive the copayment for the outpatient surgical services. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $225 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
 
  You have been asked to pay a $225 copayment for the outpatient surgical services. This item/service falls 
within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgical services 
provided on May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on May 3, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service should be 
covered. The Plan denied your request. The Plan says the service was not urgent or emergent. 
 
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 did not pre-approve the service 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 the office visit (99213) provided on May 3, 2022, by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 test kits provided on August 2, 2022. 
 
You asked the Plan to pay for COVID-19 test kits. You say that you thought you could be the tests and then 
reimbursed under your plan. The Plan denied your request. The Plan says coverage of at-home/over-the-
counter (OTC) COVID-19 diagnostic tests cannot be provided by your Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that you can get over-the-counter COVID-19 tests at 
any pharmacy or health care provider that participates in this initiative. The rules also say that enrollees cannot 
submit a claim for these tests to Medicare or their MA plan (unless covered by a supplemental benefit) for 
reimbursement under this initiative.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of COVID-19 test kits have not been met. Therefore, we decided that the Plan does not have to pay 
for COVID-19 test kits provided on August 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power scooter provided on March 30, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a power scooter. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 had network providers 
available who could have provided 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 a power scooter provided on March 30, 2022, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 90935 billed for date of service March 10, 2022. 
 
You asked the Plan to pay for code 90935. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 28, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for code 90935 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 90935 billed for date of service March 10, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97110, 97116, 97140, 97112, 97530) 
provided on December 9, 2021, to December 30, 2021. 
 
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 97110, 97116, 97140, 97112, & 97530 is not supported in the medical record. 
Specifically, the records provided are not for the dates of service billed. Based on this information, we decided 
that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pay for therapy services (97110, 97116, 97140, 97112, 97530) provided on December 9, 2021, 
to December 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share amount for the myocardial perfusion imaging, 
tomographic (SPECT) (78452) provided on June 12, 2022. 
 
You asked the Plan to waive the cost share amount for the advanced imaging service. You say that you had a 
stress test and echocardiogram. You say that you were not aware there would be a copayment involved since it 
was done in your doctor's office. You also say that you thought it would be a $35 copayment. The Plan denied 
your request. The Plan says this cost sharing was charged 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 $225 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $225 copayment for the advanced imaging service. This item/service 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 cost share amount for the myocardial perfusion imaging, tomographic (SPECT) 
(78452) provided on June 12, 2022.