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

 
We decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal 
regions (head region; lower extremities; upper extremities; rib cage; abdomen) provided from July 1, 2022, to 
August 16, 2022. 
 
You asked the Plan to pay for chiropractic manipulation of one or more of the extra-spinal regions (head 
region; lower extremities; upper extremities; rib cage; abdomen). You say that the chiropractic treatment has 
helped with your pain. The Plan denied your request. The Plan says that the Plan only covers manual 
manipulation of the spine to correct a subluxation. 
 
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 manipulation of one or more of the extra-spinal regions (head 
region; lower extremities; upper extremities; rib cage; abdomen) provided from July 1, 2022, to  
August 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 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 office visit provided on August 25, 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 an outpatient surgery provided on August 
4, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
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 $325 
copayment for in-network outpatient surgery.  
 
You have been asked to pay a $325 copayment for an outpatient surgery. However, you are being asked to pay 
$179.72 which is less than the required amount. This item/service falls within the in-network outpatient 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 an outpatient surgery provided 
on August 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided on 
April 18, 2022 to April 29, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $500 copayment per admission for Hospitalization services.  
 
 
  The enrollee has been asked to pay a $500 copayment per admission for the inpatient hospital services. This 
item/service falls within the Hospitalization services benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for inpatient hospital services provided on April 18, 2022 to April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on April 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a facility visit. You say that you rely on staff to obtain preauthorization and all 
other paperwork. You treated the beneficiary in good faith. The Plan denied your request. The Plan says there 
was no preauthorization by a primary care provider (this is different than a referral) for an out-of-network 
(OON) provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 facility visit 
provided on April 25, 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 procedure code 99156 billed for date of service March 20, 
2022. 
 
You asked the Plan to pay for procedure code 99156. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99156 is bundled into payment for code 27250. 
 
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 99156 
is a column II code to column I code 27250. 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 code 99156 billed for date of service March 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for x-ray imaging provided from July 18, 
2022, to August 9, 2022. 
 
You asked the Plan to waive the copayments for x-ray imaging. You say that the x-rays were part of the follow-
up after surgery, and you should not be billed a 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 diagnostic tests, including x-rays, performed in a specialist's office.  
 
You have been asked to pay a total copayment of $45 for x-ray imaging ($15 per x-ray x 3 x-rays = $45). 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 copayments for x-ray imaging provided from July 18, 2022, to 
August 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
August 29, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like payment to be 
made for this claim. The Plan denied your request. The Plan says this service was rendered by an OON 
provider, 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 the subsequent nursing facility care (99309) 
provided on August 29, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on May 14, 2022. 
 
You asked the Plan to pay for ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare 
covered services related or unrelated to the members terminal condition. The Medicare hospice benefit, 
through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of 
discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services 
and all care unrelated to the terminal illness until the first day of the month following the month in which 
hospice was revoked or discharged. 
 
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 ambulance services provided on May 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for Medicare Part B 
Prescription Drugs, radiology and specialist office visit provided on May 27, 2022. 
 
You asked the Plan to waive the copayment and coinsurance for Medicare Part B Prescription Drugs, radiology 
and specialist office visit. You say that you disagree with the cost share amount. 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 20% coinsurance for Medicare Part B Prescription Drugs a $100 copayment for outpatient diagnostic tests/Medicare 
covered radiological diagnostic services and a $25 copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B Prescription Drugs a $100 copayment for 
radiology and a $25 copayment for specialist office visit. The total allowed amount for Medicare drugs is $0.99 
($0.99 x 20% = $0.20). The Total copayment amount for the radiology services is $100 however, you are only 
being asked to pay $90.26 which is less than the required amount. The total amount you are being asked to pay 
is $115.46 ($.20 + $90.26 + $25 = $115.46). 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 and 
coinsurance for Medicare Part B Prescription Drugs, radiology and specialist office visit provided on May 27, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 25, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you regularly have ultrasounds, 
and the copayment charge is too high. 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 $100 
copayment for a Medicare-covered ultrasound. The total allowed amount was $96.70 which is less than the 
copayment amount of $100. Therefore, only $96.70 was charged as the copayment. 
 
  You have been asked to pay a $96.70 copayment for the ultrasound. 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 copayment for an ultrasound provided on July 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided June 8, 2021. 
 
You asked the Plan to pay for the urine PCR panel. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the PCR testing is considered unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that urinalysis is the standard of care for urinary tract 
infection (UTI). 
 
We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care 
for the diagnosis and treatment of a UTI. Based on this information, we decided that Medicare rules for 
coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay 
for the urine polymerase chain reaction (PCR) panel testing provided June 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on August 9, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copament 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 $265 
copayment for in-network ambulance services.  
 
You have been asked to pay a $265 copayment for ambulance services. This item/service falls within the in-
network 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 
services provided on August 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the scanning computerized ophthalmic 
diagnostic imaging (92134) provided on June 21, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic imaging. You say that you cannot afford to pay 
this bill. 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 $45 
copay for services for the diagnosis and treatment of diseases and injuries of the eye under the Vision care 
benefit category.  
 
 
 
 
 You have been asked to pay a $45 copay for the diagnostic imaging. This item/service falls within the Vision 
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 scanning computerized 
ophthalmic diagnostic imaging (92134) provided on June 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services (82785) provided on 
May 11, 2022. 
 
You asked the Plan to waive the copayment for the laboratory 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 $10 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $10 copayment for the laboratory services. 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 copayment for laboratory services (82785) provided on May 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided from February 28, 2022, to 
March 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that the supplies were medically necessary. 
The Plan denied your request. The Plan says a referral/authorization was not obtained prior to 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 wound care supplies provided from February 28, 
2022, to March 11, 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 eye exam provided on March 09, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for eye exam. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 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 eye exam provided on March 09, 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 a new patient office visit provided on July 11, 2022. 
 
You asked the Plan to pay for a new patient office visit. You say that a new patient visit would be necessary in 
order to plan for subsequent treatments. The Plan denied your request. The Plan says no other diagnostic, office 
visit or therapeutic service furnished by the chiropractor or under the chiropractors order is 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 a new patient office visit provided on July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90832) provided on May 10, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy 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 psychotherapy services (90832) provided on May 
10, 2022, by an out-of-network (OON) provider.