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

 
We decided that the Plan does not have to waive the copayment for an ear microscopy exam provided on 
November 9, 2021. 
 
You asked the Plan to waive the copayment for the ear exam. You say that the exam should be covered under 
the office visit copayment. The Plan denied your request. The Plan says you have been charged 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 a $15 
copayment for non-radiological diagnostic services.  
 
 
 You have been asked to pay a $15 copayment for the ear exam. This type of exam is more in-depth and is 
subject to separate cost sharing. The ear exam 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 ear 
microscopy exam provided on November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic exam of the ear provided on 
November 23, 2021. 
 
You asked the Plan to waive the copayment for diagnostic procedure. You say that this service should be 
covered under the umbrella of the comprehensive exam. The Plan denied your request. The Plan says the 
copayment amount you are being charged is correct. 
 
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 $15 
copayment for in-network non-radiological diagnostic procedure.  
 
You have been asked to pay $15 copayment for diagnostic procedure. Diagnostic procedure 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 diagnostic exam of the ear provided on November 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services received on July 14, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim processed correctly. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the services. 
Therefore, we decided that the Plan does not have to pay for immunization services received on July 14, 2021.  
 
Benefits for the services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an eye examination provided on January 5, 2022. 
 
You asked the Plan to waive the copayment for eye exam. You say that this was a routine examination that 
should have a $0 copayment. The Plan denied your request. The Plan says that the copayment amount you are 
being charged is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit the applicable Evidence of Coverage (EOC) for this 
case. Without a copy of the applicable Plan contract, we cannot determine whether the cost-sharing amount you 
have been asked to pay is appropriate. Therefore, the Plan has not shown that its decision to ask you to pay $40 
copayment is correct or justified according to Medicare rules and your contract with the Plan. Therefore, we 
decided that the Plan has to waive the copayment for an eye examination provided on January 5, 2022.  
 
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 moderate sedation services provided to the enrollee on 
September 17, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99152 (1 Unit) remains 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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
 
 
 We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not contain 
any documentation of an independent trained observer for these moderate sedation services. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for moderate sedation services provided to the enrollee on 
September 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service January 3, 
2022. 
 You asked the Plan to pay for procedure code 70544. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70553. 
 
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 70553. 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 70544 billed for date of service January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-rays rendered on December 2, 2021. 
 
You asked the Plan to pay for these services. You say that this is the first time you had these done. The Plan 
denied your request. The Plan says the services exceeded the benefit limit. 
 
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. The Plan covers one dental x-
ray per calendar year.  
 
 
 
 We looked at the file and the Plans rules. The file shows that you had complete intraoral x-rays on April 28, 
2021 that the Plan covered. The x-rays on December 2, 2021 are more than one procedure per calendar year. 
Based on this information, we decided that the Plan's rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the panoramic x-rays rendered on December 2, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on October 12, 2021. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because authorization was not obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order and/or clear intent to order 
specific lab services is required for covered lab services.    
We looked at the file and Medicare rules. The documentation submitted does not include a signed physician 
order, or - in lieu of a signed order - medical records showing clear intent to order, the specific lab services 
billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have 
not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on 
October 12, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical transport services provided to the enrollee on 
September 28, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the patient was enrolled in the hospice program. 
 
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 medical transport services provided to the enrollee on 
September 28, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90837, 90791) provided on 
October 27, 2021 to December 14, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says there were network providers available. 
 
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 services 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 these services.  Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90837, 90791) 
provided on October 27, 2021 to December 14, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Chiropractic Care provided on August 7, 2021 to November 
13, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Chiropractic Care. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
office 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 Chiropractic Care 
provided on August 7, 2021 to November 13, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 
28, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says if a laboratory assays two or more genes in a patient in parallel, then those two or more genes 
will be considered part of the same panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for laboratory services provided to the enrollee on September 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Inpatient hospital stay and Part B drugs on 
November 17, 2021 to November 24, 2021. 
 
You asked the Plan to waive the copayment for Inpatient hospital stay and Part B drugs. You say that you 
would like to appeal the cost share. The Plan denied your request. The Plan says the cost share applied was 
correct. 
 
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 $325 
copayment each day for days 1-5 for hospital care and a 20% coinsurance for Part B drugs for Inpatient 
hospital stay and Part B drugs. Your copayment total is $1,098.69 as your Maximum-Out-of-Pocket was met 
with your inpatient stay.  The allowed amount of the Part B drugs is $111.56, resulting in a coinsurance amount 
of $22.32. The total cost share amount is $1,121.01. You have been asked to pay $325 copayment each day for days 1-5 for hospital care and a 20% coinsurance for 
Part B drugs. for Inpatient hospital stay and Part B drugs. Inpatient hospital stays fall within the Inpatient 
hospital care benefit category. Part B drugs falls within the Medicare Part B prescription drugs 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 and Part B drugs on 
November 17, 2021 to November 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker purchased on July 27, 2021. 
 
You asked the Plan to pay for the walker. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was purchased from a non-Medicare out-of-network provider. 
 
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 walker purchased on July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Shingles vaccine and related administration charges you 
received on March 18, 2021, and May 18, 2021, under your medical benefits. 
 
You asked the Plan to pay for the Shingles vaccine and related administration charges under your medical 
benefits. You say that you believe it is the Plan's responsibility to route the claim to your Part D coverage. The 
Plan denied your request. The Plan says this vaccine is not covered under your medical benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles vaccine 
and related administration charges under your medical benefits. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Shingles 
vaccine and related administration charges under your medical benefits. Therefore, we decided that the Plan 
does not have to pay for the Shingles vaccine and related administration charges you received on March 18, 
2021, and May 18, 2021, under your medical benefits.  
 Benefits for the Shingles vaccine and related administration charges may be available under Medicare Part D. 
Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal 
rights.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an ultrasound of the head and neck 
provided on December 7, 2021. 
 
You asked the Plan to reduce the copayment for an ultrasound. You say that this should be covered because 
you paid a $15 copayment that day. The Plan denied your request. The Plan says you have been charged 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 up to $75 per day for diagnostic radiology services, including ultrasounds.  The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$25.29, which is 20% of the allowed amount for an ultrasound ($126.45 allowed amount x 20% coinsurance = 
$25.29). An ultrasound 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 reduce the copayment for an ultrasound of the head and 
neck provided on December 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a physical therapy visit provided on 
November 3, 2021. 
 
You asked the Plan to waive the copayment for physical therapy visit. You say that you this charge is 
inaccurate because you did not receive manual therapy at the initial visit. The Plan denied your request. The 
Plan says the copayment amount you are being charged is correct. 
 
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 
copayment for each covered physical therapy visit. The medical record shows that manual therapy was 
performed at this visit. 
 
 
 
 
 
 
 You have been asked to pay $20 copayment for physical therapy visit. Physical therapy visit falls within the 
Outpatient Rehabilitation 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 a 
physical therapy visit provided on November 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor provided to the enrollee on 
October 28, 2021. 
 
You asked the Plan to pay for the monitor. You say that this was medically necessary. The Plan denied your 
request. The Plan says the documentation provided does not include one or more of the required records to 
support payment for this service. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section.  
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 pay for the monitor. Our reviewer says that the 
service at issue int this case was not medically reasonable or necessary. Our physician reviewer found the 
enrollee has not been treated with three or more daily administrations of insulin or a Medicare-covered 
continuous subcutaneous insulin infusion pump. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not 
have to pay for a continuous glucose monitor provided to the enrollee on October 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital surgery provided on 
December 3, 2021. 
 
You asked the Plan to waive the copayment for outpatient hospital surgery. You say that you disagree with the 
surgery charge. The Plan denied your request. The Plan says the services rendered are considered surgery, thus 
the copayment amount charged is correct. 
 
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 Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical 
center, including but not limited to hospital or other facility charges and physician or surgical charges.  You have been asked to pay a $100 copayment for outpatient hospital surgery. Outpatient hospital surgery falls 
within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient 
hospital surgery provided on December 3, 2021.