Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office visit on January 10, 2022. 
 
You asked the Plan to waive the deductible for office visit. 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. Your 
contract with the Plan says that there is a $233 deductible which applies to Physician/Practitioner services, 
including doctor's office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner services, including doctor's office visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $233 deductible which applies to Physician/Practitioner 
services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at 
the time office visit was received on January 10, 2022. Therefore, we decided that the Plan does not have to 
waive the deductible for office visit on January 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 3, 2021. 
 
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 82465 is not payable. 
 
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 82465 
is a column II code to column I code 80061 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the laboratory services rendered on June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on September 9, 2021. 
 
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 80307 and G0482 are 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 80307 is drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures. The definition of code G0482 is definitive drug testing, 15-21 
drug classes. 
 
We find that CPT code 80307 and G0482 are not supported in the medical record. Specifically, there is no 
documentation of presumptive drug testing to support code 80307 and no documentation of definitive drug 
testing of 15-21 drug classes to support code G0482. 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 drug testing rendered on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for infusions provided on February 1, 2022, to 
February 15, 2022 
 
You asked the Plan to waive the copayment for infusions. You say that you should not need to pay these 
copayments. The Plan denied your request. The Plan says the copayments applied were 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 for Outpatient Infusion therapy.  
 
 
 
 
 
 
 You have been asked to pay a $583.92 coinsurance for infusions. Infusions falls within the Outpatient Infusion 
Therapy 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 infusions provided on 
February 1, 2022, to February 15, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hydration infusion on February 18, 2022. 
 
You asked the Plan to waive the copayment for hydration infusion. 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 $275 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges. The provider billed in the 
amount of $887.99 and the allowed amount is $244.44. This is less than the copayment amount. Therefore, 
results in the total cost sharing amount of $244.44. 
 
 
 
 You have been asked to pay a $244.44 copayment, which is less than the copayment amount for hydration 
infusion. Hydration infusion falls within the Outpatient surgery and other medical services 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 waive the 
copayment for hydration infusion on February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided to the 
enrollee on March 23, 2022. 
 
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that the phone call did 
not happen and this is a doctor the enrollee has never seen. 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 a $30 copayment for specialist telehealth visits.  
 
The records show that a phone call from the specialists office was performed on March 23, 2022. Therefore, 
the enrollee has been asked to pay a $30 copayment for the specialist telehealth visit. The specialist telehealth 
visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 a specialist telehealth visit provided to the enrollee on 
March 23, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the psychiatric diagnostic evaluation 
provided on May 3, 2022. 
 
You asked the Plan to waive the copayment for the psychiatric evaluation. You say that you feel the service 
should be covered. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for each individual therapy visit.  
 
You have been asked to pay a $25 copayment for the psychiatric evaluation. The psychiatric evaluation falls 
within the Outpatient Mental Health 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 the psychiatric diagnostic evaluation provided on May 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered from January 10, 2022, to 
January 14, 2022. 
 
You asked the Plan to pay for these services. You say that it is unclear why the procedures were not paid. The 
Plan denied your request. The Plan says the services were rendered by opt-out providers. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by providers who 
have opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
surgical services rendered from January 10, 2022, to January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing rendered on February 2, 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. 
 
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. 
 
We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on February 2, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G device. 
 
You asked the Plan to pre-approve the MyoPro Motion G device. You say that the MyoPro Motion G would 
immediately restore the patient's arm function and range of motion by allowing him to volitionally control 
motors at the elbow and hand portions of the brace. The Plan denied your request. The Plan says current 
medical literature does not consider this device to be standard treatment for the patient's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pre-approve the MyoPro Motion G device. Our 
reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found at this time the requested robotic orthosis is not proven to be more beneficial for 
treatment of the patient's medical condition/function of hemiparesis after stroke than any available standard 
therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced 
movement therapy, conventional muscle strengthening, and botox for spasticity if needed. The requested 
device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or  to improve the 
functioning of a malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The 
MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature 
that the MyoPro Orthosis will improve the long term outcomes for this patient, improve hemiparetic arm 
function, or be safe for long term use. There is insufficient evidence in the literature that this device will 
increase participation in bimanual activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MyoPro Motion G device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the MyoPro Motion G device.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided December 30, 
2021. 
 
You asked the Plan to pay for the emergency room services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the records do not support the code 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 code 99285 is not supported in the medical record. Specifically, review indicates that there 
was no immediate threat to life or complex medical decision making to support CPT 99285. Based on this 
information, we decided that Medicare rules for coverage of the emergency room services have not been met. 
Therefore, we decided that the Plan does not have to pay for emergency room services (99285) provided 
December 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for electrocardiogram (EKG) on April 13, 
2022. 
 
You asked the Plan to waive the copayment for electrocardiogram (EKG). 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 $200 
copayment for each Medicare-covered diagnostic procedure and test. Covered services include but are not 
limited to other outpatient diagnostic tests. The provider billed in the amount of $135 and the allowed amount 
is $92.40. The provider also billed in the amount of $70 and the allowed amount is $16.15. $92.40 + $16.15 = 
$108.55. This is less than the copayment amount. Therefore, results in the total cost sharing amount of $108.55. 
 
 
 You have been asked to pay a $108.55 copayment, which is less than the copayment for electrocardiogram 
(EKG). Electrocardiogram (EKG) 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 electrocardiogram (EKG) 
on April 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services on March 04, 2022. 
 
You asked the Plan to waive the copayment for outpatient services. 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 $290 
copayment for each Medicare-covered outpatient hospital facility visit. We cover medically-necessary services 
you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. Covered 
services include but are not limited to the following and cost sharing may apply services in an emergency 
department or outpatient clinic, such as observation services or outpatient surgery. 
 
 
 
 You have been asked to pay a $290 copayment for outpatient services. Outpatient services fall within the 
Outpatient hospital 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 copayment for outpatient 
services on March 04, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on May 6, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you dont think you should 
have to pay so much, it was only a minimal procedure and you thought you would only have a $30 copayment. 
The Plan denied your request. The Plan says the copayment applied is correct 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $195 
copayment per visit, per provider, per day for outpatient surgery performed in an ambulatory surgical center.  
 
 
 
 
 You have been asked to pay $195 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient Surgery, Including Services 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 waive the copayment for outpatient surgery provided 
on May 6, 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 April 21, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you never had to pay this in 
the past, so you dont know why you have to now. The Plan denied your request. The Plan says the copayment 
applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $35 
copayment per provider per day for each Medicare covered specialist office visit.  
 
You have been asked to pay $35 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided on April 7, 2022 by an out-of-
network (OON) provider. 
 
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 were rendered by a non-participating provider without prior authorization. 
 
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. Although the contract with the Plan 
states that enrollees may receive services from an out-of-network providers, prior authorization is required for 
surgical services from an out-of-network provider. 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 surgical services provided on April 7, 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 hospital discharge day management rendered on April 
21, 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 separately payable. 
 
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the 
same specialty must bill and be paid as though they were a single physician. 
 
We looked at the file and Medicare rules. The file shows that procedure code 99239 was billed on the same 
date of service by a physician in the same practice as code 99232, which was covered by the Plan. 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 hospital discharge day management rendered on April 21, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a lab visit provided on March 3, 2022. 
 
You asked the Plan to waive the copayment for a lab visit. You say that you have never been charged for a lab 
visit before and do not understand why you're getting one now. The Plan denied your request. The Plan says the 
copayment applied was 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 $10 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay a $10 copayment for a lab visit. A lab visit falls within the Outpatient Diagnostic 
Tests and Therapeutic Services For Lab 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 
copayment for a lab visit provided on March 3, 2022.