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

 
We decided that the Plan does not have to pay for procedure code 99358 billed for date of service May 31, 
2022. 
 
You asked the Plan to pay for procedure code 99358. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99358 is bundled into payment for code 99306.  
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 99358 
is a column II code to column I code 99306. 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 99358 billed for date of service May 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance oxygen and oxygen supplies, routine disposable 
supplies, and rhythm electrocardiogram (ECG) provided on October 13, 2021.  

You asked the Plan to pay for ambulance oxygen and oxygen supplies, routine disposable supplies, and rhythm 
ECG. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for ambulance oxygen and oxygen supplies, routine disposable 
supplies, and rhythm electrocardiogram (ECG) provided on October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services can be provided by a network 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 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 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 12, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment for ambulance services.  
 
The enrollee has been asked to pay a $250 copayment for ambulance services. However, you are only being 
asked to pay $249.35. This item/service falls within the ambulance services benefit category. This means that 
the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for ambulance services provided on May 12, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an outpatient mental health visit provided 
on August 16, 2022. 
 
You asked the Plan to reduce the copayment for an outpatient mental health visit. You say that you think the 
copayment should be $20. 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 outpatient mental health care. 
 
You have been asked to pay a $40 copayment for an outpatient mental health visit. This item/service falls 
within the outpatient mental health 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 reduce the copayment 
for an outpatient mental health visit provided on August 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
October 25, 2022. 
 You asked the Plan to pay for the eye refraction. You say that you have never been advised that this is not 
covered. The Plan denied your request. The Plan says this service is only covered when performed by a 
network routine vision provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by a network routine vision optometrist as part of a 
routine eye exam. 
 
We looked at the file and the Plan's rules. In this case the refraction was not performed by a routine vision 
optometrist as part of a routine eye exam. Based on this information, we decided that the Plan's rules for 
coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for 
the determination of refractive state (92015) provided on October 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0266). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that this bed is medically necessary. 
The Plan denied your request. The Plan says this type of bed is non-covered under Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0266).
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 
29, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like the Plan to reconsider their 
denial of payment. 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 29, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673) provided 
on July 21, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was medically 
necessary. The Plan denied your request. The Plan says this device was for use outside the home and is non-
covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for a pneumatic compression device (E0675, E0673) provided on July 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 15, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee was in a nursing home and 
authorization could not be obtained. 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 the laboratory services 
provided on July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7140) and analgesia (D9230) for tooth #26 
and #27 provided on April 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that the extractions were authorized, and you did not 
receive a bill until a year later. The Plan denied your request. The Plan says the denial of payment for the 
extractions is correct because they are not covered by the Plan. Also, the anesthesia was denied since there was 
no covered service performed. 
 
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 extractions are not among those 
covered under this benefit. Since there was no covered procedure the anesthesia is not a covered service. 
Therefore, we decided that the Plan does not have to pay for the extractions (D7140) and analgesia (D9230) for 
tooth #26 and #27 provided on April 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Synvisc injection provided on June 27, 
2022. 
 
You asked the Plan to waive the coinsurance for the Synvisc injection. You say that you were not alerted that 
you would have any responsibility for additional payment. 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% 
coinsurance of the total cost for other Medicare-covered Part B drugs when received out-of-network. 
 
You have been asked to pay a 40% coinsurance for the Synvisc injection ($504.39 allowed x .40 = $201.76). 
This item/service falls within the Medicare Part B prescription drugs benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for the Synvisc injection provided on June 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests and an office 
visit provided on March 23, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests and an office visit. You say that you 
disagree with the cost share. 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 $50 
copayment and a $10 copayment for outpatient diagnostic tests and physician/practitioner services.  
 
You have been asked to pay a $50 copayment for outpatient diagnostic tests and a $10 copayment for an office 
visit. The total amount you are being asked to pay for the diagnostic test is $37.50 which is less than the 
required amount. The total amount you are being asked to pay for the services is $47.50 ($37.50 + $10 = 
$47.50). 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 diagnostic tests and an office visit 
provided on March 23, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided October 28, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 skilled nursing services provided October 28, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an E-visit provided on September 2, 2022. 
 
You asked the Plan to waive the copayment for an E-visit. You say that the technical issue happened during the 
E-visit. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $0 copayment for Physician/Practitioner services, including 
doctor's office visits.  
 
The Plan says you must pay $30 copayment for an E-visit. Based on the Plan contract, however, you cannot be 
asked to pay more than $0 copayment for an E-visit. Therefore, we decided that the Plan has to waive the 
copayment for an E-visit provided on September 2, 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 an oral evaluation (D0120) and bitewings (D0274) provided 
on September 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing because you did not exhaust 
your benefit coverage. The Plan denied your request. The Plan says your benefit for the requested items or 
services 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. On April 29, 
2022, the Plan paid for an oral evaluation (D0140) and intraoral radiographic images (D0220); therefore, the 
record shows your benefit for the requested items or services was exhausted on the date of service of April 29, 
2022. Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0120) and bitewings 
(D0274) provided on September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a traveling lab service milage provided on November 22, 
2021. 
 
You asked the Plan to pay for a traveling lab service milage. You say that this was medically necessary and 
should be covered. 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 a traveling lab service 
milage provided on November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 24, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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 August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on October 03, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. 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 office visit provided on 
October 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on September 14, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you are disputing the share cost. 
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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for an office 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 office visit provided on September 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on May 03, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. 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 lab testing provided on 
May 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on October 19, 2020. 
 
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 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 office visit provided on 
October 19, 2020.