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

 
We decided that the Plan does not have to pay for four units of unlisted neurological or neuromuscular 
diagnostic procedure (95999) provided on June 30, 2021. 
 
You asked the Plan to pay for unlisted neurological or neuromuscular diagnostic procedures. You say that these 
services were billed appropriately. The Plan denied your request. The Plan says the medical records do not 
support these services 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. In this case, the CPT Code Manual definition of 
code 95999 is unlisted neurological or neuromuscular diagnostic procedure. 
 
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 unlisted neurological or neuromuscular diagnostic 
procedures. Our reviewer says that these services are not supported as billed. Our reviewer found the provided 
procedure report does not include documentation of what unlisted neurological or neuromuscular diagnostic 
procedure is being reported for, and therefore this code cannot be verified. When reporting unlisted procedure 
codes, documentation should support the procedure being reported. The healthcare plan documents the unlisted 
procedure code is being reported "train of four" testing. There is no CPT code assignment for this procedure, as 
it is inclusive to the billed intraoperative neuromonitoring code and is not reported separately. 
 
  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of unlisted neurological or neuromuscular diagnostic procedures have not been 
met. Therefore, we decided that the Plan does not have to pay for four units of unlisted neurological or 
neuromuscular diagnostic procedure (95999) provided on June 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
February 11, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the ambulance 
service was not requested by you or the enrollee. The Plan denied your request. The Plan says the enrollee was 
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 a $275 copayment for each one-way ambulance transport.  
 
The enrollee has been asked to pay a $275 copayment for the ambulance transportation. The ambulance 
transportation falls within the 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 transportation provided on February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital visit provided from 
November 3, 2021, to December 14, 2021. 
 
You asked the Plan to waive the copayment for the outpatient hospital visit. You say that the services should be 
covered as you disagree with the charges. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
 
  You have been asked to pay a $2,010 copayment for 9 outpatient hospital visits. 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 visit provided from November 3, 2021, to December 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a shoulder x-ray provided on February 25, 
2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you had the same x-ray done in this 
office on December 7, 2021, which did not have a 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 $50 
copayment for x-rays performed in an outpatient hospital setting. The contract also says if your provider bills 
us as part of a hospital system, you may be responsible for the outpatient hospital setting cost share for the 
services outlined in this section. 
 
The record shows the x-ray on February 25, 2022 took place in an outpatient hospital. You have been asked to 
pay a $50 copayment for an x-ray. An x-ray 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 a shoulder 
x-ray provided on February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for continuous positive airway pressure 
(CPAP) supplies provided on December 16, 2021. 
 
You asked the Plan to waive the coinsurance for CPAP supplies. You say that you never had to pay for CPAP 
supplies with your last plan. 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 for in-network durable medical equipment.  
 
You have been asked to pay a total of $60.21 for CPAP supplies. CPAP supplies falls within the Durable 
Medical Equipment (DME) and Related Supplies benefit category.  
 
Code Allowed Amount 20% Coinsurance 
A7038 $16.26 $3.25 
A4604 $46.63 $9.33 A7046 $15.20 $3.04 
A7035 $23.78 $4.76 
A7031 $85.32 $17.06 
A7030 $113.83 $22.77 
Total  $60.21 
 
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 continuous positive airway pressure (CPAP) supplies 
provided on December 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a portable oxygen system and oxygen 
concentrator provided on February 13, 2022. 
 
You asked the Plan to reduce the coinsurance for a portable oxygen system and oxygen concentrator. You say 
that you disagree with total billed amount of $350. 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 for in-network durable medical equipment.  
 
 
 
 
 
 
 You have been asked to pay $3.97, which is 20% coinsurance of the allowed amount for a portable oxygen 
system ($19.83 allowed amount x 20% coinsurance = $3.97). You have also been asked to pay $20.65, which is 
20% coinsurance of the allowed amount for an oxygen concentrator ($103.26 allowed amount x 20% 
coinsurance = $20.65). You have been asked to pay a total of $24.62 ($3.97 coinsurance + $20.65 coinsurance 
= $24.62). A portable oxygen system and oxygen concentrator falls within the Durable Medical Equipment 
(DME) and Related 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 coinsurance for a portable 
oxygen system and oxygen concentrator provided on February 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee fully meets criteria for IRF. The Plan 
denied your request. The Plan says the enrollee does not meet criteria and could be treated in a lower level of 
care facility such as a skilled nursing facility 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that 
this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on November 
13, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that the services should be 
covered as you disagree with the charges and thought there was no charge for COVID-19 testing. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for Urgently needed services.  
 
 
  You have been asked to pay a $50 copayment for the urgent care visit. The record indicates that the urgent care 
visit was to address an insect bite. 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 urgent care visit 
provided on November 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on April 11, 2021. 
 
You asked the Plan to pay for the air ambulance services. You say that it was not appropriate for the Plan to 
recoup payment on this claim.  You said that the patient's other insurance only paid you $2500 for this service, 
so the Plan needs to pay you the balance of the Medicare-allowed amount. The Plan denied your request. The 
Plan says you have already been paid more than the Medicare-allowed amount for this service, so no further 
payment is due. 
 
 
 
 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that you must accept, as payment in full, the 
Medicare-allowed amount for services.  In this case, both you and the Plan agree that the Medicare-allowed 
amount for the air ambulance services provided was $7519.00.  You claim that you were only paid $2500 by 
the patient's primary insurer, so the Plan should pay the balance of this amount.  However, the primary insurer 
has submitted evidence showing that they did not pay you $2500 for this service as you claimed, but rather 
$9602.08.  This check was mailed to you on May 25, 2021. As a result, you have already been paid more than 
the Medicare-allowed rate for the service and no additional payment is due. Based on this information, we 
decided that Medicare rules for coverage of the air ambulance services have not been met. Therefore, we 
decided that the Plan does not have to pay for air ambulance services provided on April 11, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy provided on March 18, 2021. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you should not have to pay this 
because nothing was found. The Plan denied your request. The Plan says coinsurance 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 $475 
copayment for each Medicare-covered outpatient hospital visit.  
 
You have been asked to pay $475 copayment for the colonoscopy. The colonoscopy falls within the 
Outpatient hospital visit benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. The medical records show multiple polyps were removed during the 
procedure. 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 colonoscopy provided on March 
18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee was recently hospitalized 
with hypoxic and hypercarbic acute on chronic respiratory failure. She has a diagnosis of chronic obstructive 
pulmonary disease (COPD) and obesity hypoventilation syndrome. She improved with bi-level positive airway 
pressure (BiPAP) therapy in the hospital. She may benefit from nocturnal ventilatory support as an outpatient, 
but this can be provided via BiPAP. A home ventilator is not covered when used as a BiPAP and is therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a breast biopsy provided on January 4, 
2022. 
 
You asked the Plan to reduce the copayment for a breast biopsy. You say that a representative told you that 
your copayment would be $175 since the provider was in-network. 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 $375 
copayment for in-network outpatient surgery at an outpatient hospital.  
 
The record shows this claim was approved at the in-network rate. You have been asked to pay a $375 
copayment for a breast biopsy. A breast biopsy falls within the Outpatient Surgery 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 reduce 
the copayment for a breast biopsy provided on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy (97026), a physical medicine procedure 
(97139), therapeutic activities (97530), acupuncture (97810 and 97811) and extraspinal chiropractic 
manipulative treatment (98943) provided on October 25, 2021, through November 3, 2021. 
 You asked the Plan to pay for the acupuncture and chiropractic services. You say that you would like 
reconsideration because these services were provided in good faith and rendered with the medical care the 
enrollee required. The Plan denied your request. The Plan says these services are not covered benefits. 
 
The Plan must follow Medicare rules. The rules say that auxiliary personnel furnishing acupuncture must be 
under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical 
nurse specialist. The rules also say that the only chiropractic service Medicare covers is manual manipulation 
of the spine to correct a subluxation.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture and chiropractic services have not been met. Specifically, the records indicate that the 
acupuncture services were rendered by a licensed acupuncturist, not a physician. The records do not show that 
this provider was under the supervision of a physician, physician assistant, nurse practitioner or certified nurse 
specialist. Additionally, the services at issue that were rendered by the chiropractor are not covered benefits as 
they are not manual manipulation of the spine to correct subluxation. Therefore, we decided that the Plan does 
not have to pay for infrared therapy (97026), a physical medicine procedure (97139), therapeutic activities 
(97530), acupuncture (97810 and 97811) and extraspinal chiropractic manipulative treatment (98943) provided 
on October 25, 2021, through November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic hearing exam and 
comprehensive hearing test provided on January 20, 2022. 
 
You asked the Plan to waive the copayment for a hearing exam and hearing test. You say that there should be 
no copayment for a routine hearing exam. 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 $35 
copayment for a diagnostic hearing exam. The Plan contract says that enrollees must pay a $5 copayment for a 
diagnostic test and procedures. 
 
The medical record shows you had a diagnostic hearing exam and hearing test on January 20, 2022. You have 
been asked to pay a $35 copayment for a hearing exam. A hearing exam falls within the Hearing Services benefit category. You have also been asked to pay a $5 copayment for a hearing test. You have been asked to 
pay a total of $40 ($35 copayment + $5 copayment = $40). A hearing test 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 a diagnostic hearing exam and comprehensive hearing test provided on January 20, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for psychotherapy services (90834) provided 
from January 3, 2022, to January 31, 2022. 
 
You asked the Plan to waive the deductible for the psychotherapy services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the deductible 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 $1000 deductible which applies to Outpatient mental health care.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
mental health care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$1000 deductible which applies to Outpatient mental health care. This cost sharing is a contractual obligation 
that had not been met at the time the psychotherapy services was received on January 3, 2022 to January 31, 
2022. Therefore, we decided that the Plan does not have to waive the deductible for psychotherapy services 
(90834) provided from January 3, 2022, to January 31, 2022.