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

 
We decided that the Plan does not have to pay for laboratory services provided on August 18, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 
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 laboratory services provided on August 18, 2022, 
by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter. 
 
You asked the Plan to pre-approve a knee scooter. You say that medical records were sent to show medical 
necessity. The Plan denied your request. The Plan says the enrollee wears custom orthotics and has not been 
wearing a budin splint. On exam, the bunion deformity is reducible. She has had multiple surgery appointments 
to address her condition but has postponed them due to scheduling conflicts. Most recently, she postponed the 
procedure in order to take a personal trip to Australia, which is the reasoning behind the request for the DME. 
As this is a clear recreational purpose and given the enrollee's physical aptitude and the fact that the notes give 
no indicational that she has difficulty performing any of the aforementioned MRADLs, the plan has concluded 
that the enrollee does not fulfill the required coverage criteria. 
 
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. The records show the enrollee is physically active, she walks and 
does water aerobics. Medicare rules say that the requested item is covered if all of the above criteria (1-3) are 
met. Based on this information, we decided that Medicare rules for coverage of a knee scooter have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an opthamologist visit provided on August 
29, 2022, to September 09, 2022. 
 
You asked the Plan to waive the copayment for an opthamologist visit. You say that you should not have so 
many copayments for these services 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 $25 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $25 copayment for an opthamologist visit. This item/service falls 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 copayment for an opthamologist visit provided on August 29, 2022, to September 09, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 26, 2021, 
by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you depend on hospital staff to 
verify eligibility and to obtain the proper authorization from the patient's insurance company. You also say that 
the service provided was medically necessary. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
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 subsequent nursing facility care provided on May 
26, 2021, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to medical appointments. The Plan denied your request. The Plan says you have utilized the maximum number 
of transportation trips allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on June 29, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 outpatient services provided on June 29, 2022, by 
an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) purchased on May 26, 2022, from 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that the enrollee received a notice from the Plan 
advertising hearing aid brands which included the one they purchased. You also say that you feel this was false 
advertisement, as you later were advised the provider was not part of the Plan's vendor network. The Plan 
denied your request. The Plan says you purchased these hearing aids from an OON provider. The Plan also 
says that you did not call in to the Plan's hearing department to be registered and discuss hearing aid benefits or 
referral to any in-network providers. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased from a Plan-approved hearing aid vendor.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5298) purchased on May 26, 2022, from an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64635 and 64636 billed for date of service 
May 4, 2022. 
 
You asked the Plan to pay for procedure codes 64635 and 64636. You say that the injection was performed at 
two different sides and on two different levels. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 
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 64635 is 1. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. For CPT code 64636, this code is a packaged service. No separate payment is made 
when provided at an ambulatory surgical center. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
64635 and 64636 billed for date of service May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care provided on June 30, 2022. 
 
You asked the Plan to waive the copayment for the wound care. You say that no one notified you of the cost for 
this service. You also say that you were not able to make a wiser decision due to not knowing prior to going to 
the facility. 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 $475 
copayment for each Medicare-covered non-surgical visit in an outpatient clinic.  
 
You have been asked to pay a total of $341.89 which is less than the standard $475 copayment. Wound care 
falls under the outpatient hospital 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 wound care provided on June 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urinary catheter (A4351) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the supplies. You say that you are the only provider in the area. You say that 
the enrollee's plan has honored these services up until now. You also say that this should be covered. The Plan 
denied your request. The Plan says the requested items can be provided in-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 confirmed there are 
network providers available who can provide the items at issue in this appeal. We found no exception that 
would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-
approve urinary catheter (A4351) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service April 27, 
2022. 
 You asked the Plan to pay for procedure code 11721. You say that this service was medically necessary and 
should be paid. The Plan denied your request. The Plan says payment for code 11721 is bundled into payment 
for code 11055. 
 
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 11721 
is a column II code to column I code 11055. 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 11721 billed for date of service April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pre-diagnostic test (D0431) provided on March 28, 2022. 
 
You asked the Plan to pay for the dental service. You say that you needed a tooth pulled and did not know the 
service would not be covered. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the pre-diagnostic test is not covered by the Plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pre-
diagnostic test (D0431) provided on March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
January 7, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you don't agree with 
the copayment. 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 $150 
copayment for outpatient hospital services/outpatient hospital facility.  
 
You have been asked to pay a $150 copayment for outpatient hospital services. This item/service falls within 
the outpatient hospital services/outpatient hospital facility 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 hospital services provided on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on July 19, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
  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 office visit provided on July 19, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
August 31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim denied correctly. 
 
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. 
 
You are not a network provider with the Plan. The Plan did not pre-approve the service 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 subsequent nursing facility care (99309) provided on August 31, 2022, by an out-of-
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy provided on July 14, 2022 
 
You asked the Plan to waive the copayment for an endoscopy. You say that you don't agree with the 
copayment. 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 outpatient surgery/Medicare-covered surgery.  
 
You have been asked to pay a $250 copayment for an endoscopy. This item/service falls within the outpatient 
surgery/Medicare-covered surgery 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 endoscopy provided on July 14, 2022
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker (E0143), provided on June 21, 2022. 
 
You asked the Plan to pay for the walker. You say that you couldn't get this item anywhere else. The Plan 
denied your request. The Plan says the item obtained by the member was rendered by a provider who is not 
under contract with the health plan and is not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the walker (E0143), provided on June 
21, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99217 billed for date of service February 17, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the initial or 
subsequent observation code was not found in the enrollee's claim history. 
 
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 99217 is observation care discharge day management. 
The medical records show that the enrollee received care from February 14, 2022, to February 17, 2022. We 
find that CPT code 99217 is supported. The approval of this code is not contingent upon when other claims 
associated with this period of care is submitted. Based on this information, we decided that Medicare rules for 
coverage of the billed services have been met. Therefore, we decided that the Plan has to pay for procedure 
code 99217 billed for date of service February 17, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service August 2, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
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 76700 is a column II code to column I code 93976. 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 76700 
billed for date of service August 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for date of service November 4, 
2021 to November 10, 2021. 
 
You asked the Plan to pay for procedure code S9500. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9500 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9500 billed for date of service November 4, 2021 to November 10, 2021.