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

 
We decided that the Plan does not have to waive the copayment for a wound debridement procedure performed 
on February 10, 2022. 
 
You asked the Plan to waive the copayment for the wound debridement. You say that you were not seen by the 
provider on this date. 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 visit for surgery or other services.  
 
The record shows that a debridement procedure was performed on February 10, 2022. Therefore, you have 
been asked to pay a $325 copayment for the wound debridement. The wound debridement 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 a wound debridement 
procedure performed on February 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
January 2, 2022, to January 5, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were under the 
impression the hospital stay would be covered in full. 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 $275 per 
day for days 1-5 and $0 after day 5, each time you are admitted to an acute care hospital. You have been asked to pay $825 ($275 copayment x 3 days) for the inpatient hospital stay. An inpatient 
hospital stay falls within the Inpatient hospital 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 an inpatient hospital stay provided from January 2, 2022, to January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 19, 2021. 
 
You asked the Plan to pay for the laboratory services. 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, we have confirmed that code 81406 
is a column II code to column I code 81443. This claim has not been billed with an appropriate modifier to 
bypass the edit.  
 
We find that the remaining denied CPT codes are not supported in the medical record. Specifically, the testing 
at issue in this case should be reported with CPT code 81479 only. 
 
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 provided on February 19, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (31500, 99291) provided October 15, 
2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says original Medicare is liable for payment for this service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician services (31500, 99291) provided October 15, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames and progressive lens provided on September 16, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the frames and progressive lens. You say that this treating provider is cheaper for 
frames than an in-network provider. The Plan denied your request. The Plan says this service was rendered 
OON without urgent or emergent need. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the services are obtained from a provider in the Plan's vision 
vendor network. 
 
We looked at the file and the Plan's rules. Services obtained from vendors outside the Plan's vision vendor 
network are not covered. Based on this information, we decided that the Plan's rules for coverage of the frames 
and progressive lens have not been met. Therefore, we decided that the Plan does not have to pay for the 
frames and progressive lens provided on September 16, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mastoplexy provided on November 9, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the mastoplexy. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the mastoplexy provided on November 9, 2021, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the office visit (99212) and the transthoracic 
echocardiography (93306) rendered by the out-of-network (OON) provider on May 18, 2021. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider and do not meet criteria for coverage. 
 
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 issue reimbursement 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to issue reimbursement for these services. Therefore, we 
decided that the Plan does not have to issue reimbursement for the office visit (99212) and the transthoracic 
echocardiography (93306) rendered by the out-of-network (OON) provider on May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 11, 2021. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that it was the assisted living facility 
responsibility to get authorizations for their patients. The Plan denied your request. The Plan says our policy 
requires non-par providers to obtain a prior authorization to see our members. 
 
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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 21, 2021. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81551) provided November 17, 2021. 
 
You asked the Plan to pre-approve the genetic testing. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. In this case, ConfirmMDx was ordered at the same time as the 
biopsy. There was no previous negative biopsy documented in the records. Based on this information, we 
decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genetic testing (81551) provided November 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (64561, 76000) provided November 9, 
2021. 
 
You asked the Plan to pay for surgical services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 codes 64561, & 76000 are not supported in the medical record. Specifically, the record does 
not show this procedure was performed bilaterally. The plan requested additional information, and none was 
provided. Since the primary procedure was not supported, the component code (76000) is not eligible for 
payment.  
 Based on this information, we decided that Medicare rules for coverage of surgical services have not been met. 
Therefore, we decided that the Plan does not have to pay for surgical services (64561, 76000) provided 
November 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for a magnetic resonance 
imaging (MRI) of the pelvis with contrast provided on January 31, 2022. 
 
You asked the Plan to waive the copayment and coinsurance for the MRI with contrast. You say that the 
provider website did not mention any copayments for the imaging. The Plan denied your request. The Plan says 
the correct copayment and coinsurance was applied. 
 
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 $175 copayment for diagnostic imaging, including MRI's. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for medical supplies, which 
includes contrast agents. 
 
You have been asked to pay a $175 copayment for the MRI. You have also been asked to pay $25.11 for the 
contrast agent, which is 20% of the allowed amount ($125.56 allowed amount x 20% coinsurance = $25.11). 
The total for the visit is $200.11. The MRI with contrast 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 and 
coinsurance for a magnetic resonance imaging (MRI) of the pelvis with contrast provided on January 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from 
December 15, 2021. 
 
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 Request for Anticipated Payment (RAP) required in order to process final per Medicare 
guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The case file does not show that a valid RAP was submitted in this case. 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 home health services provided to the enrollee from December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided by a network 
provider on October 15, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you were tested for 
coronavirus and did not realize you would be charged an office visit copayment. You say no medical services 
were rendered. The Plan denied your request. The Plan says you have been asked to pay 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 covered office visit to other providers for urgently needed services.   
 
You have been asked to pay a $25 copayment for the urgent care visit. The urgent care visit falls within the 
Urgently needed services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. The record shows vitals were obtained, and physical exam rendered. 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 urgent care visit provided by a network provider on 
October 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 5, 
2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that the ambulance ride should be 
covered. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $290 copayment for emergency and non-emergency ambulance, per date of service, regardless of 
the number of trips for ground ambulance.  
 
 
  The enrollee has been asked to pay $290 for ambulance services. Ambulance services fall within the 
Ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance services provided on May 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the copayment for magnetic resonance imaging (MRI) 
(72157) provided on December 9, 2021. 
 
You asked the Plan to reimburse the copayment for the MRI. 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 $105 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $105 copayment for an MRI. MRIs 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 reimburse the copayment 
for magnetic resonance imaging (MRI) (72157) provided on December 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a scleral cover shell (prosthetic eye) 
provided on February 7, 2022. 
 
You asked the Plan to waive the coinsurance for the prosthetic eye. You say that you were under the 
impression that prosthetic eyes were fully covered. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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 each prosthetic or orthotic device, such as prosthetic eyes.  
 
You have been asked to pay $351.94, which is 20% of the allowed amount for the prosthetic eye ($1,759.68 
allowed amount x 20% coinsurance = $351.94). The prosthetic eye falls within the Prosthetic Devices and Related Supplies benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a scleral cover shell 
(prosthetic eye) provided on February 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on 
January 25, 2022. 
 
You asked the Plan to pay for code 70450. 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, we have confirmed that code 70450 
is a column II code to column I code 70496. 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 the Computed tomography (CT) scan (70450) provided on 
January 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
September 4, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you did not request 
the ambulance. You say that you were forced to go. 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 $250 
copayment for each one-way ambulance trip.  While the service may not have been requested, the file shows that transportation was provided. Therefore, you 
have been asked to pay a $250 copayment for the ambulance transportation. The ambulance transportation falls 
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 transportation provided on September 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on December 3, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that the services were provided in good faith The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
 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 home health services provided on December 3, 
2021 by an out-of-network (OON) provider.