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

 
We decided that the Plan does not have to waive the copayment for a duplex scan (93971) provided on 
February 4, 2021. 
 
You asked the Plan to waive the copayment for the duplex scan. 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 $145 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 
  You have been asked to pay a $117.73 copayment for a duplex scan, which is less than the standard $145. 
Duplex scans fall 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 duplex scan (93971) provided on February 4, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Surgical Pathology Procedures provided on January 17, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Surgical Pathology Procedures 
. You say that you would like to request reconsideration of the denied claim. The Plan denied your request. The 
Plan says we did not receive a PCP referral to review and approve and authorization is required prior to an out-
of-network visit. 
 
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 Surgical Pathology Procedures provided on 
January 17, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided by a non-plan provider on January 
24, 2022. 
 
You asked the Plan to pay for the hearing aids provided by a non-plan provider. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says you received 
hearing aids from a non-plan provider. Hearing aids are only covered under the Plan when provided by a Plan 
provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when provided by a Plan provider. 
 
We looked at the file and the Plan's rules. The provider you received your hearing aids from is a non-plan 
provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not 
been met. Therefore, we decided that the Plan does not have to pay for the hearing aids provided by a non-plan 
provider on January 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromonitoring services (95940) provided December 17, 
2021. 
 
You asked the Plan to pay for the neuromonitoring services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with 
another 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. In this case, we have confirmed that code 95940 
is a column II code to column I code 95955. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for neuromonitoring services (95940) provided December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for opioid treatment (G2067) provided March 14, 2021. 
 
You asked the Plan to pay for the opioid treatment. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the provider is not eligible for payment for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that to participate in the Medicare program and 
receive payment, an opioid treatment program must be enrolled in the Medicare program, have in effect a 
certification by the Substance Abuse and Mental Health Service Administration (SAMHSA) for the opioid 
treatment program, be accredited by an accrediting body approved by the SAMHSA and have in effect a 
provider agreement under Title 42 of the Code of Federal Regulations (CFR), Section 489. 
 
We looked at the file and Medicare rules. The provider is not registered on the CMS list of Opioid Treatment 
Program (OTP) providers. Based on this information, we decided that Medicare rules for coverage of the 
opioid treatment have not been met. Therefore, we decided that the Plan does not have to pay for opioid 
treatment (G2067) provided March 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits provided from February 14, 
2021 to February 21, 2021. 
 
You asked the Plan to waive the copayment for office visits. You say that all of the office appointments were a 
result of the surgery on February 14, 2021. You say that these copayments should not have been charged. 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 services rendered in a specialist's office.  
 
 
 
 
 
 You have been asked to pay a total of $120 ($30 x 4 visits = $120). Office visits fall 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 copayment for office visits provided from February 14, 2021 to February 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital procedure provided 
on October 19, 2021. 
 
You asked the Plan to waive the copayment for the outpatient hospital procedure. You say that you are 
experiencing financial hardship at this time and need assistance. The Plan denied your request. The Plan says 
the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 
copayment for all other Outpatient Services not provided in an Ambulatory Surgical Center.  
 
 
  You have been asked to pay the allowed amount of $303.27 rather than the standard $400 copayment for the 
outpatient hospital procedure. The outpatient hospital procedure 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 the outpatient hospital procedure provided on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on May 27, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you did not see the provider on the 
date of service in question. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for office visits to specialists at an independent office.  
 
You have been asked to pay $40 for the office visit. The office 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 the office visit provided on May 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a transvaginal ultrasound provided on 
February 24, 2022. 
 
You asked the Plan to reduce the copayment for the ultrasound. You say that you were informed that the 
copayment would only be $15. 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 $75 
copayment for diagnostic procedures and tests, such as ultrasounds.  
 
You have been asked to pay a $75 copayment for the ultrasound. The ultrasound 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 reduce 
the copayment for a transvaginal ultrasound provided on February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for specialist visit on January 5, 2022. 
 
You asked the Plan to waive the deductible for specialist visit. You say that if you knew you had a deductible, 
you would not have gone to the appointment. 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. Your 
contract with the Plan says that there is $500 in- and out-of-network deductible which applies to certain items 
and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Podiatry Services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 
deductible which applies to specialist visits. This cost sharing is a contractual obligation that had not been met 
at the time specialist visit was received on January 5, 2022. Therefore, we decided that the Plan does not have 
to waive the deductible for specialist visit on January 5, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient surgery services provided from January 14, 2021, through 
January 17, 2021. 
 
You asked the Plan to pay for the inpatient surgery services. You say that you would like this claim 
reprocessed for medical necessity. The Plan denied your request. The Plan says that this service is not covered 
as the proper certification was not obtained. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan denied coverage saying that proper certification was not 
obtained. However, no information was provided concerning what certification was absent. The Plan has failed 
to substantiate their denial regarding what documentation is missing required for payment.  Therefore, we 
decided that the Plan has to pay for the inpatient surgery services provided from January 14, 2021, through 
January 17, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit (99283) 
provided on January 7, 2022. 
 
You asked the Plan to waive the copayment for the ER 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 $90 
copayment for Emergency care.  
 
 
  You have been asked to pay a $90 copayment for the ER visit. 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 emergency room (ER) visit (99283) provided on January 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for laboratory services provided on December 
16, 2021. 
 
You asked the Plan to waive the copayments for laboratory services. You say that you are disabled and live 
only on social security. 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 $40 
copayment for out-of-network laboratory services.  
 
You have been asked to pay a total of $28.04, which is less than the $40 copayment for each laboratory 
services on December 16, 2021.  
 
Code Copayment 
83036 $9.71 
85025 $7.77 80053 $10.56 
Total $28.04 
 
Laboratory services fall 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 copayments for laboratory services provided on December 16, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy with a stomach biopsy 
provided on January 31, 2022. 
 
You asked the Plan to waive the copayment for an endoscopy. You say that these tests were preventive and 
medical necessary to avoiding further treatments. 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 $245 
copayment for outpatient surgery at an outpatient hospital.  
 
The medical record shows you had an endoscopy which is not considered a preventive procedure. You have 
been asked to pay a $245 copayment for an endoscopy. An endoscopy 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 an endoscopy with a stomach biopsy provided 
on January 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ankle foot orthosis (L1970) provided on 
September 15, 2021. 
 
You asked the Plan to waive the coinsurance for the ankle foot orthosis. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
 
  You have been asked to pay a 20% coinsurance for the ankle foot orthosis (total allowed is $1,272.16 x 20% = 
$254.43). Ankle foot orthosis fall within the Medicare Part B prescription drugs benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for ankle foot orthosis (L1970) provided on September 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for microslide consultation services (88321) provided on 
November 17, 2021. 
 
You asked the Plan to pay for microslide consultation services. You say that you would like this claim 
reprocessed and reviewed for payment. The Plan denied your request. The Plan says this service is bundled and 
not eligible for separate payment. 
 
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 88321 
is a column II code to column I code 88323 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 microslide consultation services (88321) provided on November 17, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to waive the copayment for telephone assessment provided on January 18, 2022. 
 
You asked the Plan to waive the copayment for a telephone assessment. You say that you did not go to this 
appointment or see this provider. The Plan denied your request. The Plan says that you have been charged the 
correct cost sharing amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records showing if a telephone assessment 
took place on January 18, 2022. Without the medical records we are unable to determine if the cost sharing 
amount applied is correct. The Plan confirmed and the record shows no cost sharing was applied to the 
COVID-19 test. Therefore, we decided that the Plan has to waive the copayment for telephone assessment 
provided on January 18, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex procedure. 
 
You asked the Plan to pre-approve the Coflex procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 Coflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Coflex device is experimental. More research is needed to show safety and 
efficacy. 
 
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 Coflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Coflex procedure.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the critical care services (99291) provided on September 23, 2021. 
 
You asked the Plan to pay for the critical care services. You say that you would like this claim reprocessed 
based on medical necessity. The Plan denied your request. The Plan says that this service was previously billed 
and paid to another provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied payment claiming that this service was 
previously paid. No evidence was provided that this claim was paid to another provider. Therefore, we decided 
that the Plan has to pay for the critical care services (99291) provided on September 23, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.