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

 
We decided that the Plan does not have to pay for an office visit (99214) provided on September 22, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says a non-participating provider rendered the services, and a non-participating 
provider referred the member. The Plan has 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 an office visit (99214) provided on September 22, 
2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for surgery services provided from October 8, 
2021, to October 17, 2021. 
 
You asked the Plan to waive the copayments for the surgery services. You say that the services should be fully 
covered by the Plan. The Plan denied your request. The Plan says the proper copayments were 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 $395 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges. The total allowed amount 
for each date of service was $196.08 which is lower than the copayment amount of $395. Therefore, the 
copayment for each date of service was $196.08. The total copayment amount for all the dates of service was 
$1,960.80 ($196.08 copayment amount x 10 dates of service). 
 You have been asked to pay a $1,960.80 copayment for the surgery services. The surgery services falls within 
the Outpatient Surgery and Other Medical 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 copayments for surgery services 
provided from October 8, 2021, to October 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 10, 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. The rules say that laboratories shall not report multiple individual CPT 
codes describing the component test results. 
 
We find that the various 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. Therefore, we decided that the Plan does not have 
to pay for the laboratory services provided on June 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on November 
11, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the facility is free-
standing and you were billed incorrectly. 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 laboratory services provided at an outpatient hospital facility.  
 
The file shows that the Plan confirmed the location was a hospital laboratory facility. Therefore, you have been 
asked to pay $21.39, which is less than the $35 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 November 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME), 
commode chair, provided on November 8, 2021. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you did not 
order this, and that you were not told there was a charge for it. The Plan denied your request. The Plan says the 
coinsurance amount charged is correct. 
 
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 20% 
coinsurance for each Medicare-covered durable medical equipment item.  
 
 You have been asked to pay $13.80 for durable medical equipment (DME), which is 20% of the Plans 
approved amount of $69.02. Durable medical equipment (DME) 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 durable 
medical equipment (DME), commode chair, provided on November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for endoscopic procedures (00731) provided 
on March 29, 2021. 
 
You asked the Plan to pay for the anesthesia for endoscopic procedures (00731). You say that the provider was 
certified on the date of service and eligible to perform the anesthesia service. You say that the registry form 
should be reviewed, and the claim reconsidered for payment. The Plan denied your request. The Plan says a 
provider or multiple providers on the claim in question are not approved to receive Medicare benefits. 
 
The Plan must follow Medicare rules. Medicare rules say providers and prescribers who are currently revoked 
from Medicare, are under an active reenrollment bar, and CMS has determined that the underlying conduct that 
led to the revocation is detrimental to the best interests of the Medicare program are excluded from receiving 
payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the anesthesia for endoscopic procedures (00731) have not been met. Therefore, we decided that 
the Plan does not have to pay for the anesthesia for endoscopic procedures (00731) provided on March 29, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery services provided on November 12, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the surgery services. You say that you would like the claim reviewed and to be 
reprocessed for payment. The Plan denied your request. The Plan says the rendering provider is an out-of-
network provider and there was no referral from the enrollee's primary care physician. 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 surgery services provided on November 12, 2021, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI provided by an in-network 
provider on February 24, 2020. 
 
You asked the Plan to waive the copayment for the MRI. You say that you met your out-of-pocket max of 
$10,000 prior to this date of service. The Plan denied your request. The Plan says the copayment applied is 
correct. This claim was processed on February 29, 2020. As of that date, you had met $426.90 of the out-of-
pocket costs. You can find this information on page 3 of the Explanation of Benefits dated March 10, 2020. 
 
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 
copay for diagnostic radiology services, other than computed tomography (CT) scans, from an in-network 
provider other than your primary care physician.  You have been asked to pay a $250 copay for the MRI. The MRI falls within the Outpatient diagnostic tests 
and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the MRI provided by an in-network provider on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the Part B injections and specialist visit 
provided by a network provider on October 11, 2021. 
 
You asked the Plan to waive the cost share for the Part B injections and the specialist office visit. You say that 
you were told your infusions would be covered in full and the cost would be included in the office visit. 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 20% 
coinsurance for injections or durable medical equipment and prosthetic/orthotics if supplied by the physician, 
in addition to office visit copayment and a $30 copayment for each in-network Medicare-covered specialist 
visit.  
 
You have been asked to pay $1,740.05 which is 20% of the allowed amount for the Part B injections. The 
allowed amount is $8,700.25. ($8,700.25 x 20% = 1,740.05). You have been asked to pay $30 copayment for 
the specialist office visit. ($1,740.05 + $30 = $1,770.05). The Part B injections and the specialist office visit 
fall 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 cost share for the Part B injections and specialist visit provided by a 
network provider on October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telephone evaluation provided on October 18, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the telephone evaluation. You say that the provider is credentialed, and the claim 
should be paid without an authorization because they are an in-network provider. The Plan denied your request. 
The Plan says the rendering provider is a non-participating provider and there was no referral from the 
enrollee's primary care physician or an approved authorization. Also, there was no evidence that the service 
rendered was 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 a telephone evaluation provided on October 18, 
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 x-ray services provided on December 8, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the x-ray services. You say that you would like for the claim to be reconsidered 
and paid for the services provided. The Plan denied your request. The Plan says the rendering provider is an 
out-of-network provider and there was no 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 x-ray services provided on December 8, 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 an office visit (99204) and routine venipuncture (36415) 
provided on November 15, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and routine venipuncture. You say that your Plan coverage was 
and is retro-active to November 1, 2021, and the charges were in that window. You also say that you had 
changed your primary care provider and that you were not aware that you had to get all of your ducks in a row 
to change your primary care provider before you got service. The Plan denied your request. The Plan says this 
provider is not a network provider with the Plan, and 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. The 
record shows that there was coverage at the time of service, however, the provider was not in-network with the 
Plan. Therefore, we decided that the Plan does not have to pay for an office visit (99204) and routine 
venipuncture (36415) provided on November 15, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for X-rays of the knee provided on September 
14, 2021. 
 
You asked the Plan to waive the deductible for the X-rays. You say that you feel the Plan should pay for the 
service. The Plan denied your request. The Plan says the correct amount was applied to your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $1,000 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $1,000 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the X-rays were done on September 14, 
2021. Therefore, we decided that the Plan does not have to waive the deductible for X-rays of the knee 
provided on September 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services (97530) provided on October 1, 2021. 
 
You asked the Plan to pay for the therapy 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 the services of an OTA shall not be billed as 
services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the 
qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of occupational therapy have not been met. Specifically, the billing provider is a nurse practitioner, 
and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional 
services. Therefore, we decided that the Plan does not have to pay for the therapy services (97530) provided on 
October 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an evaluation and management services provided on 
December 14, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an evaluation and management services. You say that you tried to get a retro-
authorization, but it was denied, and the services provided to the enrollee was out of medical necessity. The 
Plan denied your request. The Plan says the rendering provider is an out-of-network provider and there was no 
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 evaluation and management services provided 
on December 14, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray examination of the shoulder (73030) provided on 
October 7, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for x-ray examination of the shoulder. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says this provider is out-of-network with the Plan, 
and authorization was not obtained prior to the services being rendered. 
 
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 x-ray examination of the shoulder (73030) 
provided on October 7, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 1, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that it was medically necessary to provide the 
enrollee with the test. The Plan denied your request. The Plan says the rendering provider is an out-of-network 
provider and there was no referral from the enrollee's primary care physician 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 the laboratory services provided on December 1, 
2021, by an out-of-network (OON) provider.