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

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 7, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you feel you pay too 
many copayments. 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 $30 
copayment for medical care or surgery services in a specialty physician's office.  
 
You have been asked to pay a $30 copayment for the specialist office visit. The specialist 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 a specialist office visit provided on December 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 15, 2020, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were unaware that an authorization was needed 
for the services rendered. The Plan denied your request. The Plan says the rendering provider is an out-of-
network provider and there was no referral from an in-network provider or an approved authorization. Also, the 
service rendered was not urgent or emergent. 
 
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 an office visit provided on December 15, 2020, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telephone evaluation and management 
service by a physician or other qualified health care professional (99442) provided November 30, 2021. 
 
You asked the Plan to waive the copayment for the telephone evaluation and management service. You say that 
you don't feel you should have a copayment for a short phone call. 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 specialist visits. 
 
 You have been asked to pay a total of $20 for the telephone evaluation and management service. The telephone 
evaluation and management service fall within the Physician/practitioner services, including doctors office 
visits benefit category. This means that you have been asked to pay less than or equal to 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 
telephone evaluation and management service by a physician or other qualified health care professional 
(99442) provided November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia for dental surgery (41899). 
 
You asked the Plan to pre-approve the anesthesia for dental surgery. You say that the services are medically 
necessary. The Plan denied your request. The Plan says this procedure is not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
anesthesia for dental surgery (41899).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Fluid Flow injections provided on November 9, 2021. 
 
You asked the Plan to pay for Fluid Flow injections. The Plan denied your request. The Plan says the Fluid 
Flow injections are 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 pay for Fluid Flow injections. Our reviewer says 
that the requested Fluid Flow injections are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this 88-year-old female was being treated for pain in the left knee; patellar 
tendinitis, left knee; and other specific arthropathies not elsewhere classified, left knee.  She presented with chronic pain and degenerative joint disease, which is becoming worse and affecting her 
expected and routine daily functions. Amniotic fluid GF is recommended. The exam revealed joint laxity 
upon anterior and posterior orthopedic drawer tests. Severe palpable swelling and inflammation is noted along 
the left patellar tendon, indicating chronic tendonitis and myositis, which required further study with diagnostic 
sonographic real-time imaging. Crepitus is noted on flexion of the right knee. However, there is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception to guidelines. Therefore, the Fluid Flow 
injections provided were 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 Fluid Flow injections have not been met. Therefore, we decided that the Plan 
does not have to pay for Fluid Flow injections provided on November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on December 
31, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the charge should be 
included in your annual visit. 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 no 
coinsurance, copayment, or deductible for the annual wellness visit. Certain services rendered during a routine 
exam may take a copayment. 
 
Your contract with the Plan also clearly says that you must pay a $15 copayment for each lab test. 
 
You have been asked to pay a $15 copayment for the laboratory services. The 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 laboratory services provided on December 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient observation services provided on July 17, 2021. 
 
You asked the Plan to pay for outpatient observation services. The Plan denied your request. The Plan says the 
provider is not in-network and there is no authorization on file. 
 
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 outpatient observation services provided on July 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prolonged office visit (99417) provided on August 20, 
2021. 
 
You asked the Plan to pay for a prolonged office 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 99417 has a status indicator of I on the Physician Fee Schedule. This means that it is invalid for 
Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of a 
prolonged office visit have not been met. Therefore, we decided that the Plan does not have to pay for a 
prolonged office visit (99417) provided on August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services (92014, 92015, 1036F) provided 
on March 5, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmological services. You say that you were unaware that this provider was 
not contracted and needed prior authorization. You also say that this error was not caught sooner due to short 
staffing from the coronavirus (COVID-19). The Plan denied your request. The Plan says the rendering provider 
is a non-participating provider and there is no referring provider involved in these services. The Plan also says 
that they did not authorize any services for this provider. 
 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 ophthalmological services (92014, 92015, 1036F) 
provided on March 5, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99222) provided on November 7, 2021. 
 
You asked the Plan to pay for initial hospital care. You say that this claim has been incorrectly denied as a 
duplicate charge; this service has only been billed once. The Plan denied your request. The Plan says a previous 
initial hospital care code has been billed by a physician with the same specialty for the same inpatient 
admission on November 5, 2021. This service should be billed with an appropriate subsequent hospital care 
code. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99222 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
We find that CPT code 99222 is not supported in the medical record. Specifically, the record shows that a code 
for initial hospital care was already billed and paid for date of service November 5, 2021. The initial hospital 
care was provided for the same inpatient admission and was provided by a physician with the same specialty. 
Based on this information, we decided that Medicare rules for coverage of initial hospital care have not been 
met. Therefore, we decided that the Plan does not have to pay for initial hospital care (99222) provided on 
November 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing (0242U) provided on November 14, 
2021. 
 
You asked the Plan to pay for Guardant360 testing. You say that this is a covered service. The Plan denied your 
request. The Plan says this was not ordered by a physician. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to be covered, laboratory services must 
be related to a patients illness or injury (or symptom or complaint) and ordered by a physician. 
 
We looked at the file and Medicare rules. The record shows that the plan reached out to the ordering physician 
listed on the claim, who confirmed that he did not order the testing at issue. Based on this information, we 
decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that 
the Plan does not have to pay for Guardant360 testing (0242U) provided on November 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 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 this is not medically necessary. 
 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation is insufficient to support that coverage criteria for the genetic testing in this case. The 
clinical documentation does not support that the test results will provide the clinician with information that will 
improve patient outcomes and/or change physician care and treatment of the enrollee in this case, and that risk 
assessment will change the management of the enrollee. The test was performed in the absence of clinical signs 
and symptoms of disease. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on April 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a respiratory assistance device (VPAP) 
provided on December 2, 2021. 
 
You asked the Plan to waive the coinsurance for the VPAP device. You say that you no longer owe any rental 
fees after the first 13 months. 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 durable medical equipment (DME), including VPAP devices.  
 
Please note that the Plan does is not responsible for agreements made with the provider. You may contact the 
provider directly with any questions regarding your rental contract status. You have been asked to pay $20.50, 
which is 20% of the allowed amount for the VPAP device ($102.51 allowed amount x 20% coinsurance = $20.50). The VPAP device falls within the Durable Medical Equipment (DME) 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 respiratory assistance device (VPAP) 
provided on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye specialist office visit provided on 
December 2, 2021. 
 
You asked the Plan to waive the copayment for the eye specialist visit. You say that you did not receive proper 
treatment and you should not be responsible for the copayment. 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 $35 
copayment for eye exams to diagnose and treat diseases and conditions of the eye.  
 
You have been asked to pay a $35 copayment for the eye specialist visit. The eye specialist visit falls within the 
Vision 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 eye specialist office 
visit provided on December 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
December 11, 2020, to December 14, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you should not be 
responsible since it took so long to receive the bill. 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 $250 per 
day for days 1-7 for each inpatient admission, up to a maximum of $1,750.  
 
The file shows that you were in the hospital from December 11, 2020, to December 14, 2020, but there is no 
copayment for the discharge date.  Therefore, you have been asked to pay $250 per day for the first 3 days of inpatient hospital care. The total for 
your stay is $750 ($250 copayment x 3 days = $750). The inpatient hospital care 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 inpatient hospital care 
provided from December 11, 2020, to December 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 5, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 procedure code 70450 billed for date of service December 5, 
2021.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the emergency ambulance services (A0429-RW) provided on June 8, 
2021. 
 
You asked the Plan to pay for the ambulance services. You say that these were ET3 ambulance services, and 
the "W" modifier is appropriate in this case. The Plan denied your request. The Plan says that modifier "W" is 
an invalid destination modifier on ambulance claims. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We find that CPT code A0429-RW is supported in the medical record. Specifically, modifier W is an 
appropriate destination modifier for use with ET3 ambulance claims. Based on this information, we decided 
that Medicare rules for coverage of the ambulance services have been met. Therefore, we decided that the Plan 
has to pay for the emergency ambulance services (A0429-RW) provided on June 8, 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.