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

 
We decided that the Plan does not have to waive the deductible for the laboratory services provided on July 19, 
2022. 
 
You asked the Plan to waive the deductible for the laboratory services. You say that the services should be 
fully covered. The Plan denied your request. The Plan says this cost sharing was charged 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 $500 
deductible for laboratory tests. 
 
You have been asked to pay a $500 deductible for the laboratory services. This item/service falls within the 
laboratory tests 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 deductible for the laboratory services 
provided on July 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 17, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are requesting a reconsideration for the 
denied payment. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist telehealth services provided on 
August 26, 2022. 
 
You asked the Plan to waive the copayment for specialist telehealth services. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says this cost sharing was charged 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 each covered visit or consultation in an outpatient location with a specialist. The Plan contract 
also says that enrollees must pay the cost-sharing that applies to specialist physician services for Medicare-
covered telehealth services received from a specialist.  
 
 
 You have been asked to pay $40 for specialist telehealth services. This item/service falls within the specialist 
telehealth 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 specialist telehealth 
services provided on August 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 31237 billed for date of service July 13, 
2022. 
 
You asked the Plan to pay for procedure code 31237. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 31237 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 31237 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 31237 billed for date of service July 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the documents attached support these services. The Plan 
denied your request. The Plan says there is no authorization on file for the services. 
 
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 May 31, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
22, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. 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 September 22, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous positive airway pressure (cpap) device (E0601) 
provided on June 23, 2022. 
 
You asked the Plan to pay for a cpap device. You say that after months of unavailability to procure a cpap 
machine per pulmonologists orders and spending many hours with plan agents trying to help you find a 
machine with no luck, you had to purchase a machine out of network. You were informed on July 24th, that 
coverage was only allowed for rental equipment. The Plan denied your request. The Plan says Medicare does 
not reimburse this item as a lump-sum purchase. Medicare requires this item to be billed as a continuous rental 
up to a maximum of 13 months. The Plan has asked your provider to resubmit this claim as a rental claim. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare does not reimburse this item in a lump sum. Rental 
equipment is billed month to month, up to a 13-month maximum. Based on this information, we decided that 
Medicare rules for coverage of a cpap device have not been met. Therefore, we decided that the Plan does not 
have to pay for a continuous positive airway pressure (cpap) device (E0601) provided on June 23, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99213 billed for date of service May 19, 2022. 
 
You asked the Plan to pay for the billed code. You say that the services were provided in good faith. The Plan 
denied your request. The Plan says that the code is included within the global surgery period of code 28805. 
 
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 99213 is supported in the medical record. The file shows that the office visit at issue 
was provided for wound care. This office visit was provided 2 days prior to procedure code 28805. The 
medical records do not show that this visit determined a need for procedure 28805. This was not a pre-
operative visit after the decision was made to operate. Based on this information, we decided that Medicare 
rules for coverage of the billed code have been met. Therefore, we decided that the Plan has to pay for 
procedure code 99213 billed for date of service May 19, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-complete series of radiographic images (D0210) 
provided on April 26, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the service provided was exhausted on date of service July 7, 2021. Specifically, the 
Plan provides coverage of a full mouth or complete x-ray once every three plan years. You previously received 
this service on July 7, 2021, which was paid for by the Plan. Therefore, you have exhausted the allowable 
benefit for this service. Therefore, we decided that the Plan does not have to pay for the intraoral-complete 
series of radiographic images (D0210) provided on April 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services requested are medically necessary. The 
Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do 
not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation shows that the patient has functional impairments however there are no complex functional deficits or active medical comorbidities specified thus patient would not be 
expected to require intense therapy or an acute hospitalization with an interdisciplinary approach to 
rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the follow-up office visit, eye testing, and injection to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the follow-up office visit, eye testing, and the injection. You say that you 
have been under this doctor's care for over 13 years. The Plan denied your request. The Plan says the provider 
is out-of-network. 
 
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 
the follow-up office visit, eye testing, and injection to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility visit provided on June 02, 2022. 
 
You asked the Plan to pay for nursing facility visit. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility visit 
provided on June 02, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11104 billed for date of service August 18, 
2022. 
 
You asked the Plan to pay for procedure code 11104. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 11104 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 11104 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 11104 billed for date of service August 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Dexamethasone injection provided at an 
outpatient surgery hospital provided on August 3, 2022, and August 24, 2022. 
 
You asked the Plan to waive the copayment for a Dexamethasone injection provided at an outpatient surgery 
hospital. You say that you feel the procedure should be billed as an office visit and not as an outpatient surgery. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $250 
copayment for each Medicare-covered surgery at an outpatient hospital facility.  
 You have been asked to pay a total copayment of $500 for a Dexamethasone injection in an outpatient surgery 
hospital ($250 per visit x 2 visits = $500). This item/service 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 Dexamethasone injection provided at an outpatient surgery hospital 
provided on August 3, 2022, and August 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 12, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code [insert code at issue] is 1. The MAI value for this code is 2. You billed 2 
units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage 
of procedure code [insert code at issue] have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 76641 billed for date of service August 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 26, 2022. 
 
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 that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultraviolet light therapy system provided to the enrollee 
on August 3, 2022. 
 
You asked the Plan to pay for the system. You say that this was medically necessary. The Plan denied your 
request. The Plan says the documentation submitted did not sufficiently support the billed supply code. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the documentation doesnt support that the enrollee has generalized intractable psoriasis. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pay for an ultraviolet light therapy system provided to the enrollee on August 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown (D2740) provided on July 21, 2022. 
 
You asked the Plan to pay more for the crown (2740). You say that you got the crown because your dentist 
recommended it. You say the Plan should pay for the crown. The Plan denied your request. The Plan says you 
were charged the correct cost sharing amount. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 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 50% coinsurance for the crown 
(D2740). 
 
You have been asked to pay $299 which is 50% of the allowed amount for the crown (D2740). The allowed 
amount is $598. ($598 x 50% = $299). This item/service falls within the dental 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 pay more for the crown (D2740) provided on July 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays on September 16, 2022. 
 
You asked the Plan to waive the copayment for x-rays. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $10 
copayment per day for Medicare-covered X-rays. You will only pay one copayment per day even if multiple X-
rays are performed. Covered services include, but are not limited to  X-rays. 
 
You have been asked to pay a $10 copayment for x-rays. This item/service falls within the Outpatient 
diagnostic test 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 x-rays on September 16, 2022.