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

 
We decided that the Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out-
of-network (OON) provider on October 27, 2021. 
 
You asked the Plan to pay for these services. 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, 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 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 pay for these services. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out-of-network (OON) 
provider on October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on December 22, 
2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that your card says you should owe $0 
for office visits. The Plan denied your request. The Plan says the claims were processed correctly and you are 
being charged the correct 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 primary care provider visits.  
 
You have been asked to pay a $30 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 
copayment for an office visit provided on December 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (70450, 99053) provided August 4, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the radiology services were medically 
necessary. The Plan denied your request. The Plan says the codes billed are bundled with other codes and not 
separately 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 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. Code 99053 has a status of "B" and is always bundled. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology 
services (70450, 99053) provided August 4, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for the cortisone injection procedure you had on 
September 22, 2021. 
 
You asked the Plan to reduce the copayment for the cortisone injection procedure.. You say that you had this 
procedure done in an office setting, not in an outpatient hospital facility, so your copayment should only be 
$40. The Plan denied your request. The Plan says that you were charged this copayment correctly. 
 
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 enrollees must pay a $40 copayment for surgery services in a specialist's office.  
 
The Plan says you must pay a $335 copayment for the cortisone injection procedure.  We do not agree.  It 
appears that the Plan is charging you the copayment for outpatient surgery in an outpatient hospital facility.  
The Plan has failed to provide any evidence that the facility where you received this injection is an outpatient 
hospital facility.  The medical records from this visit explicitly state that these services were done in an office 
setting.  The medical records do not show anywhere that these services occurred in an outpatient hospital 
facility.  It appears that these services occurred in a physicians office within a clinic.  There was no 
documentation submitted by the Plan showing that this clinic is an outpatient hospital facility.  The burden is 
on the Plan to prove that its assessment of cost sharing is correct.  They have failed to do so here. Therefore, we 
can only assume that these services occurred in a specialist office setting as you stated, not in an outpatient 
hospital facility. Based on the Plan contract, you cannot be asked to pay more than a $40 copayment for the 
cortisone injection procedure (which is what you agreed to pay in your appeal letter). Therefore, we decided 
that the Plan has to reduce the copayment for the cortisone injection procedure you had on September 22, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for arthrocentesis and does not have to waive 
the coinsurance for Medicare Part B drugs provided on September 3, 2021, and September 17, 2021. 
 
You asked the Plan to waive the copayments for arthrocentesis and to waive the coinsurance for Medicare Part 
B drugs. You say that you were told that the injections were approved and you would not owe anything. The 
Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct 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 specialist visits. Your contract with the Plan also clearly says you must pay 20% coinsurance for 
Medicare Part B prescription drugs. 
 
You received Arthrocentesis on September 3, 2021. Therefore, you are responsible to pay the $20 copayment.  
 
You received a Medicare Part B drug on September 3, 2021. The allowed amount is $480.48 and 20% of that is 
$96.10.   
 
You received Arthrocentesis on September 17, 2021. Therefore, you are responsible to pay the $20 copayment.  
 
You received a Medicare Part B drug on September 17, 2021. The allowed amount is $480.48 and 20% of that 
is $96.10.   
 
The total amount you owe is: $232.20.  
 
You have been asked to pay the total amount of $232.20 for arthrocentesis and Medicare Part B drugs. 
Arthrocentesis falls within the physician/practitioner services, including doctors office visits benefit category. 
Medicare Part B drugs 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 copayments for arthrocentesis and does not have to waive the coinsurance for 
Medicare Part B drugs provided on September 3, 2021, and September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled services of a registered nurse (G0162) provided 
on August 26, 2021. 
 
You asked the Plan to pay for the skilled services of a registered nurse.. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says this service was 
not billed on the appropriate claim form. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 We find that CPT code G0162 is not supported in the record. Specifically, this service was not billed on the 
appropriate claim form for Home Health Agency services. Based on this information, we decided that Medicare 
rules for coverage of the skilled services of a registered nurse. have not been met. Therefore, we decided that 
the Plan does not have to pay for the skilled services of a registered nurse (G0162) provided on August 26, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a personal emergency response system. 
 
You asked the Plan to pre-approve the services. You say that this is imperative in case you fall. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a personal emergency response system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgently needed services provided on 
October 31, 2021. 
 
You asked the Plan to waive the copayment for urgently needed services. You say that they were unable to 
perform the proper testing so you were sent to the emergency room. The Plan denied your request. The Plan 
says the claims were processed correctly and you are being charged the correct 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 $65 
copayment for urgently needed services.  
 
You have been asked to pay a $65 copayment for urgently needed services. Urgently needed services fall 
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. 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 
urgently needed services provided on October 31, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional physical therapy (PT) visits (97164). 
 
You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are 
medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not 
meet criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has had prior therapy and the documentation does not 
reveal that the enrollee requires the unique skills of a professional therapist to safely and effectively provide 
treatment, or that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. There has been enrollee and caregiver training. The requested services are not part of 
a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent 
or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ten (10) additional physical therapy (PT) visits (97164).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for durable medical 
equipment. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says network providers must be used. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for durable medical equipment.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient laboratory services provided on 
November 16, 2021, and November 22, 2021. 
 
You asked the Plan to waive the copayment for the outpatient laboratory services. You say that the services 
should be covered in full 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 $35 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
  
You have been asked to pay a $31.26 copayment for two outpatient laboratory service visits, which is less than 
the standard $35 each. Outpatient 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 copayment for outpatient 
laboratory services provided on November 16, 2021, and November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for anorectal surgery (00902) rendered by the 
out-of-network (OON) provider on November 10, 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 anesthesia for anorectal surgery (00902) rendered by the out-of-network (OON) 
provider on November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (99220, 1124F) provided on 
November 4, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for initial observation care. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The also 
says that they have also determined that these services are not urgent or emergent, nor were they 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 initial observation care (99220, 1124F) provided 
on November 4, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment of methadone (G2067) 
provided on September 6, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for medication assisted treatment of methadone. You say that you were told that no 
authorization is needed if the provider is in-network. The Plan denied your request. The Plan says this provider 
is not a network provider with the Plan and the services were not referred by a network provider or rendered in 
an in-network facility. The Plan also says that they have also determined that these services are not urgent or 
emergent, nor were they 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 medication assisted treatment of methadone 
(G2067) provided on September 6, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a patient visit (99202) provided on February 26, 2021. 
 
You asked the Plan to pay for a patient visit. You say that the service at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a patient visit (99202) provided on February 26, 2021. have been met. Specifically, the documentation submitted does not include sufficient 
clinical information. There is no documentation to support that an office visit including a medically appropriate 
history and/or examination and straightforward medical decision making was rendered on the billed date of 
service. Additionally, there is no evidence of an established relationship between the enrollee and this provider. 
Therefore, we decided that the Plan does not have to pay for a patient visit (99202) provided on February 26, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of speech, language, voice, communication, 
and/or an auditory processing disorder (92507) rendered by the out-of-network (OON) provider on March 8, 
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 treatment of speech, language, voice, communication, and/or an auditory 
processing disorder (92507) rendered by the out-of-network (OON) provider on March 8, 2021.