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

 
We decided that the Plan does not have to pay for a nail procedure with pathology provided on November 10, 
2022. 
 
You asked the Plan to pay for a nail procedure with pathology. 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 nail procedure with 
pathology provided on November 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an ambulance trip provided on December 
21, 2022. 
 
You asked the Plan to reduce the copayment for an ambulance trip. You say that you think that the copayment 
for this service should be lower. 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 $225 
copayment for each separate Medicare-covered ambulance service. 
 
You have been asked to pay a $225 copayment for an ambulance trip. This item/service falls within the each 
separate Medicare-covered ambulance service 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 ambulance trip provided on December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a nerve injection provided on October 10, 
2022. 
 
You asked the Plan to reduce the copayment for a nerve injection. You say that you do not think you should 
owe anything for this service. 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 $200 
copayment for each in-network Medicare-covered visit to an outpatient hospital facility. 
 
You have been asked to pay a $200 copayment for a nerve injection. This item/service falls within the each in-
network Medicare-covered visit to an 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 reduce the copayment for a nerve injection provided on October 10, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for residential treatment provided on February 15, 2020, to 
March 05, 2020. 
 
You asked the Plan to pay for residential treatment. 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 residential treatment 
provided on February 15, 2020, to March 05, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray and electrocardiogram (EKG) 
provided on November 29, 2022. 
 
You asked the Plan to waive the copayment for the x-ray and EKG. You say that the surgery scheduled for the 
same date of service was canceled and you should not have to pay for the x-ray and EKG. 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 Medicare-covered x-ray. Your contract also clearly says that you must pay a $40 
copayment for each Medicare-covered diagnostic test provided by a specialist, including EKGs. 
 
You have been asked to pay a $40 copayment for the x-ray. You have also been asked to pay a $40 copayment 
for the EKG. You have been asked to pay a total of $80 ($40 copayment + $40 copayment = $80). These 
items/services fall within the diagnostic tests and therapeutic 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 the x-ray and electrocardiogram (EKG) provided on November 29, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110-GP-GQ provided on August 12, 2022. 
 
You asked the Plan to pay for procedure code 97110-GP-GQ. 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 providers must report services correctly. 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, the code was billed with the GQ modifier. The GQ modifier is only valid when used by providers in Alaska or Hawaii. The rendering 
provider was not in Alaska or Hawaii. Based on this information, we decided that Medicare rules for coverage 
of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 97110-GP-GQ provided on August 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on January 20, 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 
January 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular stress test provided on November 30, 
2022. 
 
You asked the Plan to pay for the cardiovascular stress test. You say that your PCP recommended the test and 
you were not aware that authorization was required. 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 cardiovascular stress 
test provided on November 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a flu vaccine provided on October 27, 2022. 
 
You asked the Plan to pay for a flu vaccine. You say that this service is not supposed to have a charge like this. 
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 flu vaccine provided 
on October 27, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visit provided on September 20, 2022. 
 
You asked the Plan to pay for rest home 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 rest home visit provided 
on September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on November 11, 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 
November 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on 
October 25, 2022. 
 
You asked the Plan to waive the copayment for an electrocardiogram (EKG). 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). Your contract with the Plan clearly says that you must pay a $20 
copayment for outpatient diagnostic tests/Medicarecovered non-radiological diagnostic services. 
 
You have been asked to pay a $20 copayment for an electrocardiogram (EKG). This item/service falls within 
the outpatient diagnostic tests/Medicarecovered non-radiological diagnostic 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 an electrocardiogram (EKG) provided on October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on November 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service 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 requested item or service was exhausted on date of service July 2, 2019. Therefore, 
we decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on November 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient hospital services provided 
from October 26, 2022, to November 2, 2022, and the ambulance services provided on October 28, 2022. 
 
You asked the Plan to waive the copayments for the hospital stays and ambulance services. You say that you 
are unhappy with the services provided at the hospital and do not think you should have to pay. 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 $350 
copayment per day for days 1-5 of each Medicare-covered hospital stay. Your contract with the plan also 
clearly says that you must pay a $275 copayment for each in-network or out-of-network one-way ambulance 
transport. Your contract with the Plan also says there is a $5,300 out-of-pocket maximum for in-network 
services. 
 
You have been asked to pay a $350 copayment per day for each hospital stay. For your inpatient hospital stay 
from October 26, 2022, to October 29, 2022, you are being asked to pay $1,050 ($350 copayment per day x 3 
days = $1,050). For your inpatient hospital stay from October 29, 2022, to November 2, 2022, you are being 
asked to pay $749.85, which is less than the standard $350 copayment per day due to meeting your out-of-
pocket maximum. These items/services fall within the inpatient hospital care benefit category.  
 
You have been asked to pay a $275 copayment for the ambulance transport provided on October 28, 2022. This 
item/service falls within the ambulance 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 
copayments for the inpatient hospital services provided from October 26, 2022, to November 2, 2022, and the 
ambulance services provided on October 28, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reimburse for periodontal maintenance (D4910) provided on October 27, 2022. 
 
You asked the Plan to reimburse for the dental services. You say that the services should be reimbursed as you 
disagree with the denial. The Plan denied your request. The Plan says that the services denied correctly as the 
claim needs to be submitted to the third-party provider. 
 
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 Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
The Plan's denial reason for the claim needing to be sent to the third party is invalid. The third-party benefit 
administrator is considered an extension (or agent) of the Plan, so as they are required to coordinate benefits, if 
the Plan receives a claim from a provider directly, the Plan must forward that claim in a reasonable time frame 
to the third party. Therefore, we decided that the Plan has to reimburse for the periodontal maintenance 
(D4910) provided on October 27, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a facet joint injection provided on July 20, 
2021. 
 
You asked the Plan to waive the copayment for a facet joint injection. You say that you would like the 
copayment to be waived because this service was not rendered. 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 $300 
copayment for Medicare-covered surgery, provided in an outpatient hospital or an ambulatory surgical center. 
 
You have been asked to pay a $300 copayment for a facet joint injection. This item/service falls within the 
Medicare-covered surgery, provided in an outpatient hospital or an ambulatory surgical center 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 facet joint injection provided on July 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service November 
21, 2022. 
 
You asked the Plan to pay for procedure code 97010. You say that a prior authorization is already on file for 
these services. The Plan denied your request. The Plan says they have agreed to pay for the other therapy 
services; however, procedure code 97010 is considered bundled and not separately payable. 
 
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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nerve injection provided on October 13, 
2022. 
 
You asked the Plan to waive the copayment for the injection. You say that you were not aware of the 
copayment for this service. 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 $275 
copayment for outpatient surgery services provided at a freestanding ambulatory surgical center. 
 
 
 
 
 You have been asked to pay a $261 copayment for the injection because the allowed amount for this service is 
less than the $275 copayment. 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 the nerve injection provided on October 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J2001 billed for date of service December 
28, 2021. 
 
You asked the Plan to pay for procedure code J2001. You say that the records for the services are attached. The 
Plan denied your request. The Plan says payment for code J2001 is bundled into payment for code 20611. 
 
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 J2001 
is a column II code to column I code 20611. 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 J2001 billed for date of service December 28, 
2021.