Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluation and psychotherapy 
provided on May 13, 2021, to December 6, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychiatric diagnostic evaluation and psychotherapy. You say that you searched 
for an in-network counselor who specialized in eating disorders, but there were none in your area that were 
accepting new clients. The Plan denied your request. The Plan says a prior approved authorization is needed to 
seek service from a non-participating 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 psychiatric diagnostic evaluation and 
psychotherapy provided on May 13, 2021, to December 6, 2021, 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 routine foot care rendered on March 21, 
2022. 
 
You asked the Plan to waive the copayment for these services. You say that you should not owe a copayment 
for a physician's assistant. The Plan denied your request. The Plan says the copayment was applied 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 each routine foot care visit, for up to 6 visits every year.  
 
Review of the file shows that you received routine foot care on March 21, 2022. Per the contract with the Plan, 
there is a $40 copayment for each routine foot care visit, for up to 6 visits every year. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed 
amount for these services was $28.48. Given that the allowed amount was less than the $40 copayment, you 
have been asked to pay $28.48 for these services. Therefore, we decided that the Plan does not have to waive 
the copayment for the routine foot care rendered on March 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from October 15, 
2021, to November 9, 2021. 
 
You asked the Plan to pay for the home health care services. You say that you would like this claim to be 
reconsidered and reprocessed for payment. The Plan denied your request. The Plan says the non-contracted 
provider did not submit the RAP claim for services for dates of service October 15, 2021, to November 9, 
2021, until December 13, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days of the from the start of care date. Therefore, we decided that the Plan does not have 
to pay for the home health care services provided from October 15, 2021, to November 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment (DME), miscellaneous (E1399) 
DME delivery, set up, and/or dispensing service (A9901) sales tax (S9999) provided July 17, 2021. 
 
You asked the Plan to pay for the miscellaneous DME service and sales tax. You say that you are requesting 
full reimbursement for the lift chair purchased in July 2021. The cost was $1784.05, and you received a check 
for $248.66. The Plan denied your request. The Plan says the claim was reprocessed, and additional 
reimbursement was approved for $1286.73. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file, and Medicare rules. CPT codes E1399, A9901 and S999 are included in the cost of 
another service provided and separate reimbursement is not allowed and/or is not a covered benefit. Based on 
this information, we decided that Medicare rules for coverage of the miscellaneous DME service and sales tax 
have not been met. Therefore, we decided that the Plan does not have to pay for durable medical equipment 
(DME), miscellaneous (E1399) DME delivery, set up, and/or dispensing service (A9901) sales tax (S9999) 
provided July 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the 
enrollee from March 2, 2022, to March 4, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that the enrollee was not aware of 
the cost share. The Plan denied your request. The Plan says the enrollee has 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $250 per day for days 1-3 and $0 per day for additional days for each inpatient admission.  
 
The file shows that the enrollee was in the hospital from March 2, 2022, to March 4, 2022. Since there is no 
copayment for the discharge date, the enrollee has been asked to pay $250 per day for days 1-2 of inpatient 
care. The total for the stay is $500 ($250 copayment x 2 days = $500). The inpatient care falls within the 
Inpatient Hospital Coverage benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
inpatient hospital care provided to the enrollee from March 2, 2022, to March 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polycarbonate lenses and lens tints rendered on April 5, 
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 the services are not covered. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers routine vision care from an in-network provider only. 
 
We looked at the file and the Plan's rules. The file shows that you did not see a provider in the Plans vision 
care network. 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 polycarbonate lenses and lens 
tints rendered on April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on April 8, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that it was medically necessary to treat the 
enrollee and you would like the claim paid. The Plan denied your request. The Plan says the rendering and 
referring providers are both OON providers 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 the nursing facility care provided on April 8, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient office visit rendered on March 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 99204 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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, the records show that code 
99232 was billed for this enrollee on June 14, 2019 from this provider; therefore, a new patient office visit 
would not apply. 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 the new patient office visit rendered 
on March 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repeat clinical laboratory diagnostic tests (87150-91, 87481-
91, 87640-91, 87653-91, 87798-91, 87801-91) billed for date of service October 20, 2021. 
 
You asked the Plan to pay for the services. You say that these services were necessary and are supported as 
billed. The Plan denied your request. The Plan says these services are not supported as billed with the modifiers 
used. 
 
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 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 record does not 
include a laboratory report to confirm that the procedure was performed and supported the appended modifier -
91. 
 
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 repeat clinical laboratory diagnostic tests (87150-91, 87481-91, 87640-91, 87653-91, 87798-91, 
87801-91) billed for date of service October 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy (PT) provided on January 20, 2022, by an 
out-of-network provider. 
 
You asked the Plan to pay for PT. You say that the service was medically necessary and justified for the 
enrollee's overall health. The Plan denied your request. The Plan says the services were received at a non-
participating facility and authorization was not obtained prior to the service. 
 
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 physical therapy (PT) provided on January 20, 
2022, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99417 billed for date of service March 11, 
2022. 
 
You asked the Plan to pay for procedure code 99417. You say that the denied service is coded correctly, and 
the medical records support the service billed. You say that the claim should be reviewed and reprocessed. 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 99417 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99417 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99417 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99417 billed for date of service March 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429), and ground mileage (A0425) provided from January 9, 2021, to January 19, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that information is not always easily obtained at 
the time of service. You say that you did not receive insurance information until March 7, 2022. You also say 
that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says the 
claim was not submitted within 12 calendar months of the dates of service in this case. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance services was not filed until March 9, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the ambulance service, basic life support, emergency transport 
(A0429), and ground mileage (A0425) provided from January 9, 2021, to January 19, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 14, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that the medical records support CPT code 90834 and 
the enrollee meets medical necessity. You say that CPT code 90834 was billed appropriately. The Plan denied 
your request. The Plan says the provider must attempt to consult the attending or primary care physician about 
the services furnished. 
 
  The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on March 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hernia repair (49553) provided on February 18, 2022. 
 
You asked the Plan to pay for the hernia repair (49553). You say that the out-of-network provider was the only 
available assistant at the time of the procedure and rendered services specifically requested by the in-network 
primary physician at an in-network facility. The Plan denied your request. The Plan says non-physician 
practitioners are not recognized as payable by Medicare. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
  In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the hernia repair (49553) provided 
on February 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on April 6, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were told the service provided 
would have been fully covered and you like for the coinsurance to be waived. The Plan denied your request. 
The Plan says the proper coinsurance was applied for the service that was rendered. Also, it was verified during 
the call that there would be a 20% coinsurance charge. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare-covered part b chemotherapy drugs and other part b drugs. The total amount allowed 
was $1,731.60 with a coinsurance amount of $346.32 ($1,731.60 total amount x 20% coinsurance). 
 
  You have been asked to pay a $346.32 coinsurance for the injection. The injection 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 coinsurance for an 
injection provided on April 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (85027, 80076, 80048, 37182) provided 
February 9, 2022 to February 10, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid 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 CPT codes 85027, 80076, 80048, & 37182 are not supported in the medical record. Specifically, 
the primary procedure (37182) is an inpatient-only procedure. The services were billed with an outpatient place 
of service. Based on this information, we decided that Medicare rules for coverage of the outpatient services 
have not been met. Therefore, we decided that the Plan does not have to pay for outpatient services (85027, 
80076, 80048, 37182) provided February 9, 2022 to February 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ambulance on November 29, 2021. 
 
You asked the Plan to waive the coinsurance for ambulance. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing 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 a 20% 
coinsurance regardless of the number of trips for ground ambulance or air ambulance. Covered ambulance 
services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that 
can provide care only if they are furnished to a member whose medical condition is such that other means of 
transportation could endanger the person's health or if authorized by the plan. Non-emergency transportation by 
ambulance is appropriate if it is documented that the member's condition is such that other means of 
transportation could endanger the person's health and that transportation by ambulance is medically required. 
The provider billed in the amount of $1,044 and the allowed amount is $589.07. The Plan paid $471.25. 
$589.07 - $471.25 = $117.82. Therefore, results in the total cost sharing amount of $117.82. 
 You have been asked to pay a 20% coinsurance for ambulance. Ambulance falls within the Ambulance services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for ambulance on November 29, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service March 9, 
2022. 
 
You asked the Plan to pay for procedure code 93010. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 93010 is bundled into payment for code 92943. 
 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 93010 
is a column II code to column I code 92943. 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 93010 billed for date of service March 9, 2022.