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

 
We decided that the Plan does not have to waive the $45 copayment for an office visit on February 3, 2022. 
 
You asked the Plan to waive the $45 copayment for an office visit. You say that you are not responsible for 
your $45 copayment because you were not informed of the cost prior to your office visit. The Plan denied your 
request. The Plan says you must pay a $45 copayment for each specialist visit for Medicare-covered services. 
 
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 $45 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay a $45 copayment for an office visit. An office visit falls within the 
physician/practitioner services, including doctor's 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 $45 copayment for an office visit on February 3, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on January 3, 
2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that it is ridiculous that the 
insurance company will not cover in full when medically necessary transportation is needed. 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 $240 
copayment for ground ambulance services.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$240 copayment for ambulance services. Ambulance services fall 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 copayment for ambulance services provided on January 3, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site 
(D7953) and guided tissue regeneration - resorbable barrier, per site (D4266) provided January 24, 2022. 
 
You asked the Plan to pay for the bone replacement graft and guided tissue regeneration. You say that the graft 
following the extraction was the best way to ensure you did not lose more teeth. The Plan denied your request. 
The Plan says bone replacement grafts are not covered under your benefits. Guided tissue regeneration is not 
covered when provided at the site of a tooth extraction. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan does not cover 
guided tissue regeneration when it is performed at the site of a tooth extraction, dental implant or missing tooth. 
 We looked at the file and Medicare rules. The Plan provided documentation showing that on the same date of 
service, the dentist performed tooth extractions. Though the Plan offers a dental benefit in excess of Medicare 
coverage, the requested items or services are not among those covered under this benefit in this case. 
Therefore, we decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - 
per site (D7953) and guided tissue regeneration - resorbable barrier, per site (D4266) provided January 24, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on December 22, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on  
December 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an ultrasound of the heart provided on 
January 12, 2022. 
 
You asked the Plan to waive the deductible for an ultrasound. You say that you had to have this test for a 
baseline prior to starting chemo treatment. You also say this claim should not have been denied. 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. Your 
contract with the Plan says that there is $1,000 deductible which applies to radiological diagnostic services, 
including ultrasounds.  
 
The record shows this claim was approved, and you have a cost sharing amount. The item or service you asked 
the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is $1,000 deductible which applies to radiological diagnostic services, including ultrasounds. This cost sharing 
is a contractual obligation that had not been met at the time an ultrasound was received on January 12, 2022. Therefore, we decided that the Plan does not have to waive the deductible for an ultrasound of the heart 
provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for at-home COVID-19 tests purchased on January 29, 2022. 
 
You asked the Plan to pay for at-home COVID-19 tests. You say that you purchased these tests because you 
heard that Medicare was going to provide coverage for these items. The Plan denied your request. The Plan 
says these tests were not covered by Medicare or the Plan on the date in question. 
 
The Plan must follow Medicare rules. Medicare did not provide coverage for at-home COVID-19 self-tests on 
the date of purchase. While the Plan offers a supplemental benefit in excess of Medicare coverage, this benefit requires eligible OTC items to be purchased through the Plans catalog. The services at issue were purchased 
from a pharmacy before April 4, 2022, when Medicare extended coverage to home COVID-19 tests. Therefore, 
we decided that the Plan does not have to pay for at-home COVID-19 tests purchased on January 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the telephone E&M service provided on 
January 25, 2022. 
 
You asked the Plan to waive the coinsurance for the telephone E&M service. You say that you were advised 
the provider was in-network. The Plan denied your request. The Plan says the coinsurance 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 when 
out-of-network, 50% coinsurance for a PCP or specialist office visit.   You have been asked to pay $28.06 for the telephone E&M service. The telephone E&M service falls within 
the Physician/Practitioner services, including doctor's 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 coinsurance for the telephone E&M service provided on January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99336) rendered by the out-of-network (OON) provider on December 6, 
2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established 
patient (99336) rendered by the out-of-network (OON) provider on December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit (G0439) rendered by the out-of-
network (OON) provider on January 11, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the annual wellness visit (G0439) rendered by the out-of-network (OON) provider on 
January 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
abdomen and pelvis provided on February 9, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you do not know why insurance did 
not cover the service. 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 $325 
copayment per day for diagnostic radiology services, such as CT scans.  
 
You have been asked to pay a $325 copayment for the CT scan. The CT scan 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 computed tomography (CT) scan of the abdomen and pelvis provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardiology specialist telehealth visit 
provided on January 28, 2022. 
 
You asked the Plan to waive the copayment for a specialist telehealth visit. You say that you are homebound 
and cannot go to the doctor's office. You also say you should not have to pay a copayment for speaking to the 
doctor on the phone. 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 $20 
copayment for a specialist telehealth visit.  
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$20 copayment for a specialist telehealth visit. A specialist telehealth visit falls within the Telehealth 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 cardiology specialist telehealth 
visit provided on January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiology catheterization services. 
 
You asked the Plan to pre-approve cardiology catheterization services. You say that the enrollee has essential 
hypertension and a family history of ischemic heart disease and other diseases of the circulatory system, as well 
as Pure hypercholesterolemia. You say that the requested procedure is required for her to keep a good health 
and for her wellbeing. The Plan denied your request. The Plan says the enrollee's echocardiogram test was 
normal, and she does not have a history of coronary artery disease. The Plan says that the records do not show 
that the enrollee is going to have high risk surgery. The Plan says that there are other tests that the enrollee can 
have to evaluate her heart arteries that are safer. 
 
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 cardiology catheterization services. Our 
reviewer says that cardiology catheterization services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a history of dyspnea, with no chest pains. She had a 
negative stress echocardiogram test. Guidelines do not support a need for cardiac catheterization in this 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 cardiology catheterization services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve cardiology catheterization services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for microsurgical techniques (69990), allograft for spine surgery 
only (20930) and autograft for spine surgery only (20936) provided on November 23, 2020. 
 
You asked the Plan to pay for microsurgical techniques (69990), allograft for spine surgery only (20930) and 
autograft for spine surgery only (20936). You say that the operative report was sent for review, and you 
attempted to get medical records sent to the right place. You say that the medical records should be reviewed, 
and the claim reconsidered for payment. The Plan denied your request. The Plan says a modifier cannot be 
billed with procedure 69990 to bypass the edit. The Plan also says procedure code 20930 and 20936 remain 
denied as bundled services are not eligible for separate reimbursement. 
 
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 69990 
is a column II code to column I code 22633 with a modifier indicator of 0. The column II code is therefore not 
payable. In addition, CPT codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that CPT codes 20930 and 20936 are not separately 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 
microsurgical techniques (69990), allograft for spine surgery only (20930) and autograft for spine surgery only 
(20936) provided on November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 4, 
2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you are appealing your cost 
share for this service. The Plan denied your request. The Plan says you have been charged the correct 
copayment 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 $30 
copayment for in-network physician specialist services. Covered services include consultation, diagnosis, and 
treatment by a specialist.  
 
 
 
 You have been asked to pay a $30 copayment for a specialist visit. The specialist visit falls 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 a specialist visit provided on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint interventions. 
 
You asked the Plan to pre-approve facet joint interventions. You say that the facet joint interventions are 
medically necessary. The Plan denied your request. The Plan says the facet joint interventions are not 
medically necessary and do not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a second confirmatory diagnostic facet joint 
procedure is considered medically reasonable and necessary in patients who meet both of the following criteria: 
The patient meets the criteria for the first diagnostic procedure; and after the first diagnostic facet joint 
procedure, there must be a consistent positive response of at least 80% relief of primary (index) pain. 
 
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 facet joint interventions. Our reviewer 
says that the facet joint interventions are not medically reasonable or necessary. Our physician reviewer found 
the criteria requires 80% pain relief from each of 2 sets of Medial branch blocks. This was not achieved and 
therefore, the request is deemed not medically reasonable or 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 facet joint interventions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint interventions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power scooter and vehicle lift (A9270, K0800) provided 
September 23, 2021. 
 
You asked the Plan to pay for the power scooter and vehicle lift. You say that the scooter and lift are medically 
necessary. The Plan denied your request. The Plan says these items are requested primarily for work-related 
activity outside the home. Equipment used outside the home is non-covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for a power scooter and vehicle lift (A9270, K0800) provided September 23, 2021.