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

 
We decided that the Plan does not have to waive the copayment for a primary care visit provided on May 13, 
2022. 
 
You asked the Plan to waive the copayment for a primary care visit. You say that you are requesting claim be 
reconsidered because you do not feel you should have a $15 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 $15 
copayment for physician/practitioner service. 
 
You have been asked to pay a $15 copayment for a primary care visit. This item/service falls within the 
physician/practitioner service 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 primary 
care visit provided on May 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you did not know an authorization was required. 
The Plan denied your request. The Plan says the rendering provider is an OON provider and there was no 
approved 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 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 an office visit provided on June 1, 2022, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test rendered outside of the United States 
provided on June 9, 2022. 
 
You asked the Plan to pay for the COVID-19 test. You say that you thought this was a covered benefit. The 
Plan denied your request. The Plan says a COVID-19 test provided outside of the United States for travel 
purposes is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that routine services required by third parties such as 
business establishments are not covered by Medicare.  
 
We looked at the file and Medicare rules. This testing was required by a third party for the purposes of routine 
travel. Based on this information, we decided that Medicare rules for coverage of screening testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the COVID-19 test rendered outside of 
the United States provided on June 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
pelvis provided on April 27, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI) of the pelvis. You say 
that you were told, per your Plan, that this facility was a free standing facility, and you would not be charged a 
copayment of $25. 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 $25 
copayment for advance imaging services at a primary care physicians office, a specialists office, or a stand-
alone imaging center. 
 
You have been asked to pay a $25 copayment for a magnetic resonance imaging (MRI) of the pelvis. This 
item/service falls within the advance imaging services at a primary care physicians office, a specialists office, 
or a stand-alone imaging center 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 
magnetic resonance imaging (MRI) of the pelvis provided on April 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive a transforaminal epidural injection provided on August 11, 
2022. 
 
You asked the Plan to waive a transforaminal epidural injection. You say that you are on a fixed income. You 
also say that you may need this injection several times and this fee is not affordable for you to pay. 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 $390 
copayment per visit for outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
  
You have been asked to pay a $390 copayment per visit for a transforaminal epidural injection. 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 a transforaminal epidural 
injection provided on August 11, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on May 19, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says that Medicare only 
covers visits if you get them from a health care provider who accepts assignment. It has been determined that 
the services were rendered by a licensed marriage and family therapist. The services are therefore not covered 
by the Plan or Medicare as this provider does not meet Medicare's standards of non-physician practitioners 
(other eligible professionals). 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist (MFT) is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist 
(MFT). Medicare says that a Marriage Family Therapist (MFT) is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on 
May 19, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on April 
21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the provider depends upon the 
office staff to verify eligibility and to obtain the proper authorization from the patients insurance. The Plan 
denied your request. The Plan says services from non-participating providers are not covered unless they are 
authorized before the services are provided. 
 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 subsequent nursing facility care (99309) provided 
on April 21, 2022, 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 telephonic services rendered on August 12, 2022. 
 
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 99443 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 99443 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 21-30 minutes of medical discussion. 
 
We find that CPT code 99443 is not supported in the medical record. Specifically, there is no documentation of 
the precise total time spent providing services. 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 
telephonic services rendered on August 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray provided on March 7, 2022. 
 
You asked the Plan to pay for the chest x-ray. You say that you do not have record of similar charges for this 
date of service. 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 14, 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 the chest x-ray have not been met. Therefore, 
we decided that the Plan does not have to pay for a chest x-ray provided on March 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. 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 laboratory services provided on April 2, 2022, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 70544 and 71045 billed for date of service 
June 12, 2022. 
 You asked the Plan to pay for procedure codes 70544 and 71045. You say that the enrollee had multiple exams 
on this date of service. The Plan denied your request. The Plan says payment for codes 70544 and 71045 is 
bundled into payment for codes 70551 and 71046. 
 
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, we have confirmed that code 70544 
is a column II code to column I code 70551. Code 71045 is a column II code to column I code 71046. This 
claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 70544 and 71045 billed for date of service June 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
February 1, 2022, through February 3, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 $325 
copayment per admission for each medically necessary inpatient stay.  
 
You have been asked to pay a $325 copayment for the inpatient hospital admission provided. 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 care provided from February 1, 2022, through 
February 3, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility (99309) provided on April 6, 
2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the service should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
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 the subsequent nursing facility (99309) provided on April 6, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 2, 
2022, to June 5, 2022, and June 9, 2022, to June 16, 2022. 
 
You asked the Plan to waive the copayment for hospital care. You say that the cost share is too high, and you 
are on a limited income. 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 $350 
copayment for days 1-5 and $0 after day 5. This inpatient hospital stay lasted 3 days and 7 days, resulting in a 
copayment amount of $2,800 ($350 per day for 3 days and 5 days = $2,800). 
 
You have been asked to pay $350 copayment for hospital care. This item/service falls within the days 1-5 and 
$0 after day 5 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 inpatient hospital care 
provided on June 2, 2022, to June 5, 2022, and June 9, 2022, to June 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
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 pre-approve SNF care. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter (OTC) COVID-19 test kits purchased 
on July 24, 2022, and July 26, 2022. 
 
You asked the Plan to pay for the OTC COVID-19 test kits. You say that this is the first time you have done 
this, and you have not received 8 tests. The Plan denied your request. The Plan says coverage of at-home OTC 
COVID-19 test kits cannot be provided by your plan. 
 
  The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the OTC 
COVID-19 test kits are an OTC item. The Plan does not offer a supplemental benefit covering this service, as 
this is not currently required by Medicare. However, for future purchases, these can be obtained with 
participating providers and covered by Original Medicare when using your Medicare card rather than your Plan 
card. Neither Medicare nor your Plan currently offers reimbursement of purchased COVID-19 tests. Therefore, 
we decided that the Plan does not have to pay for the over-the-counter (OTC) COVID-19 test kits purchased on 
July 24, 2022, and July 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS). 
 
You asked the Plan to pre-approve an SCS. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
criteria are met. 
 
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 pre-approve an SCS. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no specific clinical rationale for the 
requested spinal cord stimulator. The review has determined that the enrollee does not meet the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an SCS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a spinal cord stimulator (SCS).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided on June 
08, 2022, to June 10, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you agreed to be 
admitted. You also say you knew the seriousness of the situation. 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 $195 
copayment for per day for days 1 to five for inpatient hospital care. 
 
You have been asked to pay a $195 copayment for inpatient hospital services. This item/service falls within the 
per day for days 1 to five for 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 inpatient hospital services provided on June 08, 2022, to June 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a spinal distraction device. 
 
You asked the Plan to pre-approve insertion of a spinal distraction device. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 pre-approve insertion of a spinal distraction device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found interspinous distraction devices are experimental. More research is 
needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of a spinal distraction device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve insertion of a spinal distraction device.