Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions of an erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210 x 4) rendered by the out-of-network (OON) provider on June 4, 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 the services were rendered by an out of 
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the extractions of an erupted tooth requiring removal of bone and/or sectioning of 
tooth (D7210 x 4) rendered by the out-of-network (OON) provider on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on November 9, 2021, 
to November 10, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient hospital services. You say that you did receive an authorization for 
dates of services from November 2, 2021, to December 2, 2021, but it is for a different code, which you billed 
for. The Plan denied your request. The Plan says this provider is not a network provider with the Plan, and they 
have also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 hospital services provided on 
November 9, 2021, to November 10, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from July 
26, 2021, to July 29, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are requesting a 
review of the charges to reflect in-network. The Plan denied your request. The Plan says the proper copayment 
was applied for the dates of service and the copayment was charged at an in-network provider copayment. 
 
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 $335 
copayment per day, days 1-6 for services in-network. The total copayment for the dates of service was $1,340 
($335 copayment per day x 4 days). 
 
  You have been asked to pay a $1,340 copayment for the inpatient hospital stay. The inpatient hospital stay 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 
inpatient hospital stay provided from July 26, 2021, to July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99212) provided on 
November 18, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you met the annual out of 
pocket maximum in July 2021 so copayments should be covered. The Plan denied your request. The Plan says 
you were charged the correct cost sharing amount and the maximum out of pocket expenses were not met at the 
time of processing. 
 
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 $50 
copayment for a specialist's office visit.  
 
You have been asked to pay a $50 copayment for a specialist office visit. A specialist office visit falls within 
the physician/practitioner services, including doctors office visits 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 (99212) provided on November 18, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
August 16, 2021 and August 17, 2021. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 the emergency room visit. 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 on August 16, 2021 and August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on November 29, 2021. 
 
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says you received the 
eyewear benefit on February 25, 2021. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services every 2 years. 
 
 We looked at the file and the Plan's rules. The file shows that you received the eyewear benefit on  
February 25, 2021. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses 
have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on 
November 29, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for chiropractic manipulative treatment (98941) provided on November 23, 
2021. 
 
You asked the Plan to pay for chiropractic manipulative treatment (98941). You say that the enrollee has been 
coming to the office since 2018 and the claims have always been paid. You say that payment for the service 
should be reconsidered. The Plan denied your request. The Plan says that modifier AT must be appended to the 
chiropractic manipulation code to indicate the manipulation was for medically necessary and reasonable 
treatment of an acute subluxation or chronic subluxation. 
 
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 98941 is chiropractic manipulative treatment (CMT); spinal, 3-4 regions. 
 
We find that CPT code 98941 is supported in the medical record. Specifically, a claim form was submitted in 
the case file with the AT modifier billed with CPT code 98941. Based on this information, we decided that 
Medicare rules for coverage of chiropractic manipulative treatment (98941) have been met. Therefore, we 
decided that the Plan has to pay for chiropractic manipulative treatment (98941) provided on November 23, 
2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100), anesthesia 
complicated by emergency conditions (99140) and TAP block (64488) provided on October 18, 2021.  You asked the Plan to pay for the special anesthesia service (99100), anesthesia complicated by emergency 
conditions (99140) and TAP block (64488). You say that this service is given to manage post-operative pain 
and is considered a separate procedure from the surgical procedure. You say that the service was provided by 
the anesthesiologist at the request of the surgeon and should be reconsidered for payment. The Plan denied 
your request. The Plan says CPT codes 99100 and 99140 have a status code of B and are not eligible for 
separate payment. The Plan also says that CPT code 64488 is considered inclusive to 00790. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that the Coding Policy 
Manual also explains what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive 
Edits. 
 
We find that CPT codes 99100, 99140 and 64488 are not supported in the medical record. Specifically, CPT 
code 99100 and 99140 have a status indicator of B. This means that CPT codes 99100 and 99140 are 
considered bundled and not separately payable. In addition, we have confirmed that code 64488 is a column II 
code to column I code 00790. This claim has not been billed with an appropriate modifier to bypass the edit. 
Based on this information, we decided that Medicare rules for coverage of the special anesthesia service 
(99100), anesthesia complicated by emergency conditions (99140) and TAP block (64488) have not been met. 
Therefore, we decided that the Plan does not have to pay for the special anesthesia service (99100), anesthesia 
complicated by emergency conditions (99140) and TAP block (64488) provided on October 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
November 16, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you wish to appeal 
the copayment. The Plan denied your request. The Plan says the proper 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 $300 
copayment for each one-way Medicare covered trip.  
 
  You have been asked to pay a $300 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance 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 
ambulance transportation provided on November 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy provided by a network 
facility on November 26, 2021. 
 
 You asked the Plan to waive the coinsurance for the chemotherapy. You say that you had already met your 
maximum out-of-pocket amount and should not be charged. The Plan denied your request. The Plan says you 
have been asked to pay the correct cost-sharing amount. 
 
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 20% 
coinsurance for in-network chemotherapy drugs.  
 
You have been asked to pay $1,301.56 which is less than the 20% coinsurance for the chemotherapy. The 
chemotherapy falls within the Medicare Part B prescription drugs benefit category. The record shows you 
met your maximum out-of-pocket amount with this claim. 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 coinsurance 
for chemotherapy provided by a network facility on November 26, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility SNF care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you received oral medications and 
insulin. You had stable vital signs, your lungs were clear and were treated for pain. You were at a maximal 
assist level with transfers in the parallel bars. You do not require skilled nursing or therapy services on a daily 
basis. You do 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and the copayment for the spinal injection 
provided by a network facility on September 22, 2021. 
 
You asked the Plan to waive the deductible and the copayment for the spinal injection. You say that you were 
charged 100% between the deductible and the copayment. You say this should be covered. The Plan denied 
your request. The Plan says you have been asked to pay the correct cost-sharing amount. 
 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible that applies towards the spinal injection and a $300 
copayment which applies to Medicare-covered surgery or other services provided to you at an in-network 
outpatient hospital, including but not limited to hospital of other facility charges and physician or surgical 
charges.  
 
The spinal injection you asked the Plan to waive the deductible and the copayment for falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $1,000 deductible which applies to the spinal injection and a $300 copayment which applies to 
Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but 
not limited to hospital of other facility charges and physician or surgical charges. See chart below. 
 
Date of Service Service Allowed Amount Deductible/ 
Copayment 
Member Liability 
Sepember 22, 2021 Spinal injection $769.41 $1,000 $619.55  This is 
the amount in 
which you met the 
deductible. 
  $149.86  This is 
the remaining 
allowed amount 
after you reached 
you deductible. 
$300 $149.86  You 
have been asked to 
pay the allowed 
amount which is 
less than the 
standard 
copayment amount 
Total    $769.41 
 
This cost sharing is a contractual obligation that had not been met at the time the spinal injection was received 
on September 22, 2021. Therefore, we decided that the Plan does not have to waive the deductible and the 
copayment for the spinal injection provided by a network facility on September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and the diagnostic laryngoscopy 
(31575) rendered by the out-of-network (OON) provider on August 11, 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 the services were rendered by an out of 
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the office visit (99213) and the diagnostic laryngoscopy (31575) rendered by the 
out-of-network (OON) provider on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Methadone treatment (G0267) rendered by the out-of-
network (OON) provider on August 10, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the Methadone treatment (G0267) rendered by the out-of-network (OON) provider on 
August 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance angiography 
(MRA) (74185) provided on November 18, 2021. 
 
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 has been applied correctly to 
the service provided. 
 
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 $350 
copayment for diagnostic radiology services other than computed tomography (CT) scans when rendered by an  
in-network provider.   
 You have been asked to pay a $350 copayment for the diagnostic radiology service rendered by an in-network 
provider. 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 magnetic resonance angiography (MRA) 
(74185) provided on November 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telomerase reverse transcriptase (TERT) gene analysis 
(81345) provided on June 1, 2021. 
 You asked the Plan to pay for TERT gene analysis. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 81345 and 
0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 telomerase reverse transcriptase (TERT) gene analysis (81345) 
provided on June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82310, 82728, 83540, 83550 and 
84100) provided on September 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted by the laboratory 
failed to show that the laboratory tests reported were unrelated to treatment of ESRD. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 (82310, 82728, 83540, 83550 and 84100) provided on September 13, 2021.