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

 
We decided that the Plan does not have to waive the copayment for emergency care provided on June 18, 2022. 
 
You asked the Plan to waive the copayment for emergency care. You say that you are disputing the share cost. 
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 $90 
copayment for emergency care.  
 
You have been asked to pay $90 copayment for emergency care. 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 emergency care provided on 
June 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that this is medically required and should be 
approved. The Plan denied your request. The Plan says there are many other providers for this service in close 
distance. 
 
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 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99284) 
provided to the enrollee on August 6, 2022. 
 
You asked the Plan to pay for the services. You say that this was billed correctly. The Plan denied your request. 
The Plan says the records support 99283 instead of 99284. 
 
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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care 
with other physicians, other qualified health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not 
pose an immediate significant threat to life or physiologic function." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records support the 
level of care for CPT 99284. Therefore, CPT 99284 cannot be verified.  
We looked at this coder's review, the file, and Medicare rules. 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 emergency department services (procedure code 99284) provided to the enrollee on August 6, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 30, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service June 30, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy visits provided on August 26, 2022. 
 
You asked the Plan to pay for physical therapy visits. You say that this was medically necessary and should be 
covered. 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).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, we 
decided that the Plan does not have to pay for physical therapy visits provided on August 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on September 14, 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 enrollees network primary care physician (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving them a 
"referral." 
 
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 September 14, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a portable ventilator. Our reviewer says 
that the documentation does not support that the requested device is medically reasonable or necessary. Our 
physician reviewer found the enrollee has moderate chronic obstructive pulmonary disease and may have an 
element of obesity-hypoventilation syndrome. An arterial blood gas done while stable showed carbon dioxide 
retention. The enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume-
assured pressure support during sleep, in which this has not been tried and failed.  Medicare does not cover a home ventilator when used as BiPAP. Therefore, the enrollee does not meet criteria 
for the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says as a member of our plan, the enrollee must use network providers. If 
the enrollee receives unauthorized care from an out-of-network provider, we may deny coverage and you will 
be responsible for the entire cost. 
 
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 
power wheelchair 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 pre-approve outpatient substance abuse treatment to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient substance abuse treatment. You say that you are not happy 
with current network provider treatment. The Plan denied your request. The Plan says your request is not 
medically necessary for you at this time. 
 
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 
outpatient substance abuse treatment to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - one to three teeth 
per quadrant (D4342). 
 
You asked the Plan to pre-approve the periodontal scaling and root planing - one to three teeth per quadrant 
(D4342). The Plan denied your request. The Plan says the information submitted wasn't sufficient to show that 
coverage criteria are met. 
 
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 the 
periodontal scaling and root planing - one to three teeth per quadrant (D4342). when the services are medically 
necessary and reasonable.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the services being requested for the 
lower arch, without specifying what quadrant or teeth are being requested, and without that information, it 
cannot be determined that the services are medically necessary. Therefore, we decided that the Plan does not 
have to pre-approve periodontal scaling and root planing - one to three teeth per quadrant (D4342).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on July 25, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab testing. 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 lab testing provided on July 25, 2022, by an out-
of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
provided to the enrollee from July 31, 2022, to August 1, 2022. 
 
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 billed code 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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records more support 
the level of care represented by CPT 99283. 
 
We looked at this coder's review, the file, and Medicare rules. 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 emergency department services (procedure code 99285) provided to the enrollee from July 31, 
2022, to August 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 09, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. 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 the laboratory services 
provided on March 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue-soft (D7286). 
 
You asked the Plan to pre-approve the incisional biopsy of oral tissue-soft (D7286). You say that you need the 
biopsy to verify if it has cancer. The Plan denied your request. The Plan says this service is not covered under 
the benefit package. 
 
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 pre-approve an 
incisional biopsy of oral tissue-soft (D7286).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on July 22, 
2022, to July 29, 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 $275 
copayment for in-network outpatient surgery.  
 
You have been asked to pay a $275 copayment for an outpatient surgery. 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 July 22, 2022, to July 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93308 billed for date of service July 12, 
2022. 
 
You asked the Plan to pay for procedure code 93308. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 93308 is bundled into payment for code 33361. 
 
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 93308 
is a column II code to column I code 33361. 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 93308 billed for date of service July 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on July 27, 2022. 
 
You asked the Plan to pay for a drug test. You say that this service was medically necessary 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 drug test provided on 
July 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Medicare Part B prescription drugs and a 
specialist office visit provided on July 7, 2022. 
 
You asked the Plan to waive the copayment for a Medicare Part B prescription drugs and a specialist office 
visit. You say that you disagree with the cost share. 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 copayment for a Medicare Part B prescription drug and a $30 and physician/practitioner 
services/physician specialist.  
 
You have been asked to pay a 20% coinsurance copayment for a Medicare Part B prescription drug and a $35 
for a specialist office visit. The total allowed amount for the prescription drug is $1,825.78. The amount you 
are being asked to pay is $356.16 ($1,825.78 x 20% = $365.16). The total amount you are being asked to pay is 
$400.16 ($365.16+ $35 = $400.16). 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 Medicare Part B 
prescription drugs and a specialist office visit provided on July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network office visit provided on 
July 6, 2022. 
 
You asked the Plan to waive the copayment for an out-of-network office visit. 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 $15 
copayment for out-of-network physician/practitioner services/Medicare-covered primary care doctor visit.  
 
You have been asked to pay a $15 copayment for an out-of-network office visit. This item/service falls within 
the out-of-network physician/practitioner services/Medicare-covered primary care doctor visit. 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 out-of-network office visit provided on July 
6, 2022.