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

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs and 
prosthetic devices provided on April 25, 2022 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs and prosthetic devices. 
You say that you disagree with the coinsurance 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 for Medicare Part B prescription drugs and a 20% coinsurance for Prosthetic devices.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a 20% coinsurance 
for prosthetic devices. The total allowed amount for the prescription drugs is $7.40 but you are being asked to 
pay $1.48 ($7.40 x 20% = $1.48). The total allowed amount the prosthetic devices is $24,296.91. The total 
amount charged is $4,859.38 ($24,296.91 x 20% = $4,859.38). You are responsible for $3,863.10 which is less than the required amount. The total amount you are being asked to pay is $3,864.58 ($3,86310+ $1.48 = 
$3,864.58). 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 Medicare Part B prescription drugs and 
prosthetic devices provided on April 25, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 05, 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 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 office visit provided on August 05, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory tests provided on July 21, 2022. 
 
You asked the Plan to waive the copayment for laboratory tests. 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 $6 
copayment for outpatient diagnostic tests/laboratory tests.  
 
You have been asked to pay a $6 copayment for laboratory tests. This item/service falls within the outpatient 
diagnostic tests/laboratory tests benefits 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 
laboratory tests provided on July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on August 
24, 2022. 
 
You asked the Plan to waive the copayment for specialist 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 $35 
copayment for physician/practitioner services/specialist visit.  
 
You have been asked to pay a $35 copayment for specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 specialist office visit provided on August 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 15, 
2022 to February 13, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the additional days of SNF care are not medicinally 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from January 15, 2022, to February 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for power mobility device services provided on June 8, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for power mobility device services. You say that you were not required to obtain an 
authorization for the services. The Plan denied your request. The Plan says services from a non-participating 
provider are not covered unless preauthorized. 
 
 
 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 power mobility device services provided on June 
8, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital stay provided on August 04, 2021, to 
August 11, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient hospital stay. 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 inpatient hospital stay provided on August 04, 
2021, to August 11, 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 coinsurance and copayment for Medicare Part B drugs and 
outpatient hospital services provided on August 10, 2022. 
 
You asked the Plan to waive the coinsurance and copayment for Medicare Part B drugs and outpatient hospital 
services. 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 for Medicare Part B prescription drugs and $90 copayment and outpatient hospital services.  
 You have been asked to pay a 20% coinsurance for Medicare Part B drugs and a $90 copayment for outpatient 
hospital services. The total allowed amount for the prescription drugs is $2,303. The amount you are being 
asked to pay is $460.60 ($2,303 x 20% = $460.60). The total amount you are being asked to pay is $550.60 
($460.60 + $90 = $550.60). 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 and copayment for Medicare 
Part B drugs and outpatient hospital services provided on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service June 18, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service June 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on May 24, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the coinsurance. 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 for durable medical equipment (DME).  
 
You have been asked to pay a 20% coinsurance for DME. The total allowed amount is $778.50. You are being 
asked to pay is $155.70 ($778.50 x 20% = $155.70). 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 
durable medical equipment (DME) provided on May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for medical supplies provided on January 20, 
2022. 
 
You asked the Plan to waive the coinsurance for medical supplies. You say that this should be covered. 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 20% 
coinsurance for Medicare covered medical supplies. 
 
You have been asked to pay 20% coinsurance for medical supplies. This item/service falls within the Medicare 
covered medical 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 coinsurance for medical 
supplies provided on January 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on July 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that your new dentist needed to take new bitewing 
x-rays. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 20, 2022. 
Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on July 26, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on July 22, 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 22, 2022, 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 outpatient hospital services provided on 
June 28, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital services. 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 $475 
copayment for outpatient hospital services/outpatient hospital visit.  
 
You have been asked to pay a $475 copayment for outpatient hospital services. However, you are being asked 
to pay $136.49 which is less than the required amount. This item/service falls within the outpatient hospital 
services/outpatient hospital 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 
outpatient hospital services provided on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing home facility services provided on September 06, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for nursing home facility services. 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 nursing home facility services provided on 
September 06, 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 procedure code 99223 provided on March 22, 2022. 
 
You asked the Plan to pay for procedure code 99223. 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. 
 
In this case, the CPT Code Manual definition of code 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: 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 problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the file shows that the 
enrollee was admitted as an outpatient on the date of service at issue in this appeal. Code 99223 is an inpatient code. Based on this information, we decided that Medicare rules for coverage of code 99223 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99223 provided on March 22, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient office visit provided on February 12, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient office visit. You say that the services were necessary along with the 
testing for covid-19. The Plan denied your request. The Plan says the services were not authorized by an in-
network primary care 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 outpatient office visit provided on February 12, 
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 computed tomography angiography (CTA) of the neck 
provided to the enrollee on April 24, 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 documents do not support the services 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 70498 is "Computed tomographic angiography, neck, 
with contrast material(s), including noncontrast images, if performed, and image postprocessing." 
 
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 records provided show a 
single computed tomography angiography (CTA) of the head - CPT 70496 - was done on April 24, 2022. The 
review of the provided records showed no report of a CTA of the neck. Reimbursement for a CTA of the neck 
is not appropriate in this case, due to lack of a report detailing that exam was done.  
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 computed tomography angiography (CTA) of the neck provided to the enrollee on April 24, 
2022.