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

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided on 
October 10, 2022. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test. 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 $75 
copayment for outpatient diagnostic tests/diagnostic procedures and tests. 
 
You have been asked to pay a $75 copayment for an outpatient diagnostic test. This item/service falls within 
the outpatient diagnostic tests/diagnostic procedures and tests 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 diagnostic test provided on October 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a urology procedure to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a urology procedure. You say that you have seen other in-network providers 
who have made mistakes on this surgery, and you cannot go through that again. The Plan denied your request. 
The Plan says there are still many other providers who are in-network who you can see. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a urology procedure to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the coumadin services provided on 
February 12, 2021. 
 
You asked the Plan to waive the copayment for the coumadin services. You say that you need more 
information about this claim. 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 $40 
copayment for phyisican/practitioner services. 
 
You have been asked to pay a $40 copayment for the coumadin services. This item/service falls within the 
phyisican/practitioner 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. However, since the allowed amount is less than the standard copayment, you 
only owe $9.69. Therefore, we decided that the Plan does not have to waive the copayment for the coumadin 
services provided on February 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiological services provided on November 25, 
2022. 
 
You asked the Plan to pay for diagnostic radiological services. You say that this was medically necessary and 
should be covered. There were multiple tests done. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for diagnostic radiological 
services provided on November 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
October 7, 2021, to October 9, 2021. 
 
You asked the Plan to waive the copayment for the hospital stay. You say that you were told there was no 
additional charge for the intensive care unit. 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 per day for days 1-6 of each Medicare-covered inpatient hospital stay.  
 
You are not being charged separately for the intensive care unit services. You have been asked to pay a $295 
copayment per day for days 1-2 of the hospital stay. You have been asked to pay a total of $590 ($295 
copayment per day x 2 days = $590). You have not been charged for the day you were discharged. 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 the inpatient hospital stay provided from October 7, 2021, to October 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97813) acupuncture, without 
electrical stimulation, each additional 15 minutes (97811) acupuncture, with electrical stimulation, each 
additional 15 minutes (97814) provided July 28, 2022. 
 
You asked the Plan to pay for the acupuncture services. You say that this claim was processed out of network, 
and you are in in network provider. The Plan denied your request. The Plan says the Plan does not cover this 
expense. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the records show that the acupuncture services were 
for hip and knee pain and not for chronic low back pain. Therefore, we decided that the Plan does not have to 
pay for acupuncture, initial 15 minutes (97813) acupuncture, without electrical stimulation, each additional 15 
minutes (97811) acupuncture, with electrical stimulation, each additional 15 minutes (97814) provided July 28, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99354 billed for September 25, 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 99354 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 99354 is prolonged service(s) in the outpatient setting 
requiring direct patient contact beyond the time of the usual service; first hour (List separately in addition to 
code for outpatient Evaluation and Management or psychotherapy service, except with office or other 
outpatient services [99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215]). 
 
We find that CPT code 99354 is not supported in the medical record. Specifically, this is an add-on code that 
was not billed with a required primary procedure code. 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 procedure code 99354 billed for September 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with an in-network tertiary cardiothoracic surgeon (99214).

You asked the Plan to pre-approve an office visit with an in-network tertiary surgeon. You say that you are currently being recommended to undergo a spinal decompression surgery for a lumbar protrusion due to an extreme amount of pain in your back, hips and legs. The requested provider is very familiar with your history which has been delicate. You would like the requested providers clearance before moving forward. The Plan denied your request. The Plan says the request for a consultation with a tertiary cardiothoracic surgeon is not approved because medical records do not support medical necessity for care with a highly specialized tertiary care provider.

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 an in-network tertiary surgeon. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found at issue is the medical necessity of having you referred to an out-of-network cardio-thoracic surgeon. There are credentialed, experienced physicians within your network who could be utilized for your clinical condition. In summary, there is insufficient documentation to support the medical necessity for referral to an out-of-network provider for your management.

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 office visit with an in-network tertiary surgeon have not been met. Therefore, we decided that the Plan does not have to pre-approve an office visit with an in-network tertiary cardiothoracic surgeon (99214).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination services (74230 and 74240) 
provided on August 29, 2022. 
 
You asked the Plan to pay for procedure codes 74230 and 74240. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that this procedure will be reimbursed only when 
medically necessary and performed in one of the places listed in the Medicare Rules section. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiologic examinations have not been met. Therefore, we decided that the Plan does not have 
to pay for the radiologic examination services (74230 and 74240) provided on August 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service March 1, 
2022, to August 31, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  

We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service March 1, 2022, to August 31, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit provided on September 06, 2022. 
 
You asked the Plan to pay for a psychotherapy visit. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a psychotherapy visit 
provided on September 06, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound services (76700) provided on August 7, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for procedure code 76700 provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 ultrasound services (76700) provided on August 7, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the laboratory services provided on 
October 25, 2022, and the specialist office visit provided on October 31, 2022. 
 
You asked the Plan to waive the copayments for the laboratory services and specialist office visit. You say that 
these services were necessary prior to having surgery. 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 $5 
copayment for bloodwork drawn at a physicians office and sent to an independent lab for processing. Your 
contract with the Plan clearly says that you must pay a $40 copayment for each specialist office visit. 
 
 You have been asked to pay a $5 copayment for the laboratory services. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to 
pay a $40 copayment for a specialist office visit. This item/service 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 copayments 
for the laboratory services provided on October 25, 2022, and the specialist office visit provided on October 31, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
November 03, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you would like to 
appeal these 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room visit. 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 the emergency room visit 
provided on November 03, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on December 12, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were not made aware of the 
cost before the ultrasound and should not have to pay 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 $100 
copayment per day for a Medicare-covered ultrasound.  
 
You have been asked to pay a $100 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic test 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 December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray and cleaning (D1110, D0220) provided on 
October 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the cleaning has already been 
exhausted. The coinsurance for the intraoral x-ray applied correctly  
based on the services provided.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the cleaning exhausted on date of service February 14, 2022, and June 15, 2022. 
 
You have been asked to pay a 50% coinsurance for the intraoral x-ray. This service falls within the class 2 
basic service benefit category 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 pay for an intraoral x-ray and 
cleaning (D1110, D0220) provided on October 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a limited oral evaluation (D0140). 
 
You asked the Plan to pre-approve a limited oral evaluation. You say that the requested service is a medical 
necessity for you. The Plan denied your request. The Plan says the requested service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
limited oral evaluation (D0140).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on December 09, 2022. 
 
You asked the Plan to pay for outpatient mental health. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for outpatient mental health 
provided on December 09, 2022.