Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 2, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the services are not authorized because this provider is a non-network 
provider who does not work with the Plan, and the member was referred by a provider who also does not work 
with the member's Plan. The Plan also says they the member's primary care physician did not refer for services. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on November 2, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lead wires (A4557) provided on September 29, 2021. 
 You asked the Plan to pay for code A4557. 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 as billed. 
 
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 code A4557 has a status code of "P" under the Medicare Physicians Fee Schedule Database 
(MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into 
the payment for the services to which these codes are incident to. Therefore, we decided that the Plan does not 
have to pay for the lead wires (A4557) provided on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 20, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that treatment was provided to the enrollee out of 
medical necessity. The Plan denied your request. The Plan says the rendering provider is an out-of-network 
provider and there was no approved authorization. Also, the service rendered was not urgent or emergent. 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on July 20, 2021, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the critical care services (99291) provided on August 13, 
2021. 
 
You asked the Plan to pay for code 99291 provided on August 13, 2021. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes.  

We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based 
code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent 
providing services to the enrollee. The progress note for August 13, 2021, does not note how much time was 
spent providing services to the enrollee. As such, the provided documentation does not support the billing of 
code 99291. Based on this information, we decided that Medicare rules for coverage of code 99291 provided 
on August 13, 2021, have not been met. Therefore, we decided that the Plan does not have to pay for the 
critical care services (99291) provided on August 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cataract surgery (66984) provided on 
May 10, 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 $250 
copayment for each Medicare-covered outpatient surgery at a hospital outpatient facility.  
 
 You have been asked to pay $250 for the Medicare-covered outpatient surgery provided at a hospital outpatient 
facility. 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 cataract surgery (66984) provided on  
May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fillings (D2332 x2) provided on March 5, 2019, the 
intraoral x-rays (D0220, D0230) and cleaning (D1110) provided on April 2, 2019, the periodic oral exam 
(D0120) and cleaning (D1110) provided on July 11, 2019, and the filling (D2391) provided on September 19, 
2019. 
 
You asked the Plan to pay for the dental services. You say that you did not realize that these services had not 
been processed by your insurance, and these services should be paid. The Plan denied your request. The Plan 
says intraoral x-rays are not covered by your dental benefit. In addition, your 2019 benefit covers a maximum 
of two fillings, two cleanings, and two oral exams per year. Additional fillings, cleanings and exams are not 
covered by your benefit. You had two cleanings which were covered between January 15, 2019, and February 
26, 2019, two oral exams on January 15, 2019, and April 2, 2019, and two fillings provided from March 12, 
2019, and April 16, 2019.

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. The Plan's dental benefit 
includes up to two oral exams (periodic or comprehensive) per calendar year, one set of bitewing x-rays, two 
prophylaxes (cleanings), two fillings per calendar year, and some anesthesia as necessary with covered 
services. 
 
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 or are requested in a frequency that exceeds what is covered by this 
benefit. Therefore, we decided that the Plan does not have to pay for the fillings (D2332 x2) provided on March 
5, 2019, the intraoral x-rays (D0220, D0230) and cleaning (D1110) provided on April 2, 2019, the periodic oral 
exam (D0120) and cleaning (D1110) provided on July 11, 2019, and the filling (D2391) provided on 
September 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) provided by an 
out-of-network provider on October 10, 2020. 
 
You asked the Plan to pay for an unspecified preventive procedure. You say that you believe the Plan should 
pay for this. The Plan denied your request. The Plan says D1999 is not a covered dental benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
unspecified preventive procedure (D1999) provided by an out-of-network provider on October 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital care provided from 
May 21, 2020, to May 23, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be 
covered as you have paid less for surgeries in the past. The Plan denied your request. The Plan says the cost-
sharing applied correctly based on the services provided. the inpatient hospital copayment was assessed, and 
the previous surgeries were performed outpatient and that applies a different 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 $225 
copayment per day for days 1-7 of Inpatient hospital care.  
 
 You have been asked to pay a $450 copayment for 2 days of inpatient hospital care. 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 inpatient hospital care provided from May 21, 2020, to May 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the comprehensive oral evaluation (D0150), and 
bitewing radiographic images (x-ray) (D0274), provided on October 22, 2021. 
 
You asked the Plan to pre-approve the oral evaluation and bitewings. You say that the services should be 
covered. The Plan denied your request. The Plan says you have exhausted the Plan benefit for these services. 
 
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. Specifically, the records indicate you had already received two exams 
and one bitewings for the Plan year. This means you have exhausted the Plan benefit for these services and are 
responsible for the cost. Therefore, we decided that the Plan does not have to pre-approve the comprehensive oral evaluation (D0150), and bitewing radiographic images (x-ray) (D0274), provided on October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam provided on November 23, 
2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you were not aware that the 
provider was a specialist. 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 $25 
copayment for exams to diagnose and treat diseases and conditions of the eye.  
 
You have been asked to pay a $25 copayment for the eye exam. The eye exam 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 an eye exam provided on 
November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for endodontic therapy (D3320) provided on 
November 24, 2021. 
 
You asked the Plan to waive the coinsurance for the endodontic therapy. You say that the services should be 
covered. The Plan denied your request. The Plan says the coinsurance 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 50% 
coinsurance for Dental services.  
 
 
  You have been asked to pay a 50% coinsurance for endodontic therapy (allowed is $.1,360.00 x 50% = 
$680.00). Endodontic therapy falls within the Dental 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 coinsurance for endodontic therapy (D3320) provided on November 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the maximum out-of-pocket for a hospital visit provided on 
November 1, 2021. 
 
You asked the Plan to waive the maximum out-of-pocket for the hospital visit. You say that the services should 
be covered as you have already met your maximum out of pocket. 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. Your 
contract with the Plan says that there is a $7,000 maximum-out-of-pocket which applies to hospital services.  
 
 
  The item or service you asked the Plan to waive the maximum out-of-pocket for falls within the benefit 
category hospital services. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $7,000 maximum-out-of-pocket which applies to hospital services. The record indicates that your 
maximum-out-of-pocket costs were not met until 12/07/2021. This cost sharing is a contractual obligation that 
had not been met at the time the hospital visit was received on November 1, 2021. Therefore, we decided that 
the Plan does not have to waive the maximum out-of-pocket for a hospital visit provided on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction of a tooth (D7210) provided on June 
4, 2021. 
 
You asked the Plan to pay for the surgical extraction. You say that you would like reconsideration because you 
should only be responsible for the 50% coinsurance. The Plan denied your request. The Plan says this 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 Plans 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. Specifically, the Plan only covers simple extractions. The records indicate that the service rendered was a surgical extraction. Therefore, we decided that the Plan does not have 
to pay for the surgical extraction of a tooth (D7210) provided on June 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cataract surgery (66984) provided on 
November 15, 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 $250 
copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient 
facility.  
 You have been asked to pay a $250 copayment for the Medicare-covered surgery provided at an outpatient 
hospital facility. 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 cataract surgery (66984) 
provided on November 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound exam of the abdominal back 
wall (76770) provided on February 6, 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 $125 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a freestanding facility (such as a radiology center or medical clinic).   
 You have been asked to pay $101.30 for the Medicare-covered radiological diagnostic service provided. This is 
the Plans allowed amount for this service which is less than the applicable copayment. 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 ultrasound exam of the abdominal back wall (76770) provided on 
February 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept procedure, intraosseous radiofrequency 
ablation of the basivertebral nerve (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that attached are redacted approval letter 
showing that the Intracept procedure has been a covered benefit for other members and was not considered 
investigational and experimental. The Plan denied your request. The Plan says this procedure is considered 
investigational. There is not enough research to show that this service improves net health outcomes in patients 
with vertebrogenic back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Intracept procedure, intraosseous radiofrequency ablation of the basivertebral nerve (64628, 
64629).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance service, basic life support, 
emergency transport (A0429) rendered on August 21, 2021. 
 
You asked the Plan to waive the copayment for ambulance service, basic life support, emergency transport. 
You say that the Plan advised the member on a Thursday that she was no longer authorized to stay in a skilled 
nursing facility, and was told to leave by Saturday, which did not leave enough time for expedited authorization 
for non-emergency transport. The Plan denied your request. The Plan says you were charged the correct cost 
sharing amount, and the $250 member obligation for ambulance transportation would apply regardless of 
emergent or non-emergent status. 
 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 $250 copayment for Medicare-covered ambulance services.  
 
The enrollee has been asked to pay $203.09, which is less than the $250 copayment for ambulance service, 
basic life support, emergency transport. Ambulance service, basic life support, emergency transport falls within 
the Medicare-covered ambulance 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 ambulance service, basic life support, emergency transport (A0429) rendered on August 21, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visit on October 5, 2021. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you saw the provider virtually 
and not in the office. The Plan denied your request. The Plan says the copayment applied 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 $5 
copay for per specialist visit, in person or over the phone.  
 
 
 
 You have been asked to pay a $5 copay for the telehealth visit. The telehealth visit falls within the Doctor 
Visits section of the Cost Sharing Guide and the Physician/Practitioner services, including doctors office 
visits benefit category of the EOC. 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 telehealth visit 
on October 5, 2021.