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

 
We decided that the Plan does not have to waive the copayment for an office visit provided on May 25, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you never saw the provider and 
would like the copayment waived 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 $35 
copayment for a specialist office visit. 
 
You have been asked to pay a $35 copayment for an office visit. This item/service falls within the a specialist 
office visit 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 
May 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on July 11, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the pathology services provided on July 11, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician/practitioner service provided on 
August 9, 2022. 
 
You asked the Plan to waive the copayment for physician/practitioner service. You say that you are requesting 
reconsideration. 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 $45 
copayment for specialist's office.  
 
You have been asked to pay $45 copayment for physician/practitioner service. This item/service falls within 
the specialist's office 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 
physician/practitioner service provided on August 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician/practitioner service provided on 
August 9, 2022. 
 
You asked the Plan to waive the copayment for physician/practitioner service. You say that you are requesting 
reconsideration. 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 $45 
copayment for specialist's office.  
 
You have been asked to pay $45 copayment for physician/practitioner service. This item/service falls within 
the specialist's office 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 
physician/practitioner service provided on August 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an abdominal ultrasound provided on July 
11, 2022. 
 
You asked the Plan to waive the copayment for an abdominal ultrasound. You say that you are not wanting to 
pay for this claim as you went to the emergency room in March. You also say there was no reason to have an 
ultrasound in July for something that happened in March. 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 for an in-network standard x-ray and ultrasound. 
 
You have been asked to pay a $50 copayment for an abdominal ultrasound. This item/service falls within the an 
in-network standard x-ray and ultrasound 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 abdominal ultrasound provided on July 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test (U0002) provided on February 26, 2022. 
 
You asked the Plan to pay for the COVID-19 test. You say that you would like to be reimbursed $50 for your 
COVID-19 testing fees. The Plan denied your request. The Plan says you had the COVID-19 test performed for 
screening purposes as a prerequisite to travel to the United States. The Plan also says that Medicare does not 
cover this test solely for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that routine services required by third parties such as 
business establishments are not covered by Medicare.  
 
We looked at the file and Medicare rules. This testing was required for the purposes of routine travel. Based on 
this information, we decided that Medicare rules for coverage of screening testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the COVID-19 test (U0002) provided on February 
26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery provided on July 21, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for surgery. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says as a member of our plan, the enrollee can choose to receive care from out-of-network 
providers. However, please note providers that do not contract with us are under no obligation to treat the 
enrollee, except in emergency situations. Our plan will cover services from either network or out-of- network 
providers, as long as the services are covered benefits and are medically necessary. However, if the enrollee 
uses an out-of-network provider, the enrollees share of the costs for their covered services may be higher. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for surgery provided on July 21, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the knee injections provided on July 27, 
2022, to August 03, 2022. 
 
You asked the Plan to waive the copayment for the knee injections. You say that these were 5 minute visits, 
and you feel that all visits should be covered under one 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 
$308.26 copayment for outpatient hospital facility visits. 
 
You have been asked to pay a $308.26 copayment for the knee injections. This item/service falls within the 
outpatient hospital facility 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. The allowed amount for each injection is $154.13. Since this is less than the 
$275 copayment per the EOC, you are only responsible for the lesser amount. The total for both injections is 
$308.26. Therefore, we decided that the Plan does not have to waive the copayment for the knee injections 
provided on July 27, 2022, to August 03, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
June 19, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you had no choice 
to not take the ambulance 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 one-way Medicare-covered trip. 
 
You have been asked to pay a $200 copayment for the ambulance transportation. This item/service falls within 
the each one-way Medicare-covered trip 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 ambulance transportation provided on June 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 05, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 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 April 05, 2022, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on March 28, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on March 
28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on July 12, 2022. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says the treating 
provider states the charges were billed with a medical diagnosis. The Plan also says that eye refractions are not 
covered when they are performed during a non-routine eye exam. 
 
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 eye refractions when they are performed during a routine exam. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you did not receive a routine eye 
exam, but instead received a medical eye exam for the diagnosis of Dry eye syndrome of bilateral lacrimal 
glands. 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 eye refraction (92015) provided on 
July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on July 11, 2022.  
You asked the Plan to pay for an eye refraction. You say that you were seen for refractive services. You also 
say you did not know that this provider is out-of-network. The Plan denied your request. The Plan says eye 
refractions are only covered by your plan if performed by a participating Plan provider and performed as a 
routine screening. 
 
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 services are rendered through a Plan care provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that they only cover these services when they are 
rendered through a Plan provider. The records show that the services you received were by a non-participating 
provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of an eye 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction 
provided on July 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extremity study rendered on May 5, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 7, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the extremity study rendered on May 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital clinic visit provided on July 5, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient hospital clinic visit. You say that this was medically necessary. The 
Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also 
says that these services were not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for outpatient hospital clinic visit provided on July 5, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for Medicare part B prescription drugs and 
physician/practitioner service provided on June 29, 2021. 
 
You asked the Plan to waive the cost sharing for Medicare part B prescription drugs and physician/practitioner 
service. You say that you were shocked to get this statement. 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 $20 copayment and 20% coinsurance for Medicare-covered specialist visit and Medicare-covered Part B 
chemotherapy drugs and other Part B drugs. The allowed amounts of these Medicare Part B drugs total 
$709.05, resulting in a total coinsurance amount of $141.81. The copayment total $20, resulting total payment 
of copayment and coinsurance amount of $161.81. 
 
You have been asked to pay $161.81 for Medicare part B prescription drugs and physician/practitioner service. 
This item/service falls within the Medicare-covered specialist visit and Medicare-covered Part B chemotherapy 
drugs and other Part B 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 cost sharing for Medicare 
part B prescription drugs and physician/practitioner service provided on June 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound rendered on August 24, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the diagnosis code is not supported. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. 
 Therefore, we decided that the Plan does not have to pay for the ultrasound rendered on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography (procedure code 95886) provided 
to the enrollee on May 2, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) 95886 remains not supported. 
 
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 95886 is "Needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List 
separately in addition to code for primary procedure)." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records Our reviewer found that there must be documentation of 
five or more muscles studied, innervated by three or more nerves of four or more spinal levels. In this case, the electromyography report only shows that a needle exam was done in three muscles on the left side. No other 
muscle grousp were studied. This would not meet the definition of the CPT code under review. As a result, this 
would not have been proper coding. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for needle electromyography (procedure code 95886) provided to the enrollee on May 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept (A0432) provided on July 19, 2022. 
 
You asked the Plan to pay for the paramedic intercept. You say that you asked for an ambulance, not a 
paramedic. The Plan denied your request. The Plan says this service is not covered in your area. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York.  
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept (A0432) provided on July 19, 2022.