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

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided on 
December 28, 2021. 
 You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not payable as they were 
rendered by an ineligible provider type. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services provided in this case were 
rendered by a licensed acupuncturist who was not under the supervision of a physician, physicians assistant, 
nurse practitioner, or clinical nurse specialist. Therefore, we decided that the Plan does not have to pay for the 
acupuncture treatment (97810, 97811) provided on December 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88304 billed for date of service July 11, 
2022. 
 
You asked the Plan to pay for procedure code 88304. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 88304 is bundled into payment for code 17311.  
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 88304 
is a column II code to column I code 17311. 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 88304 billed for date of service July 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 15, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health visit provided on June 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that you would like the claim processed for 
payment. The Plan denied your request. The Plan says the rendering provider is an OON provider and there 
was no referral from an in-network provider or an approved 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 home health visit provided on June 2, 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 provided on August 2, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the rendering provider sent the specimens to 
your lab to process. The Plan denied your request. The Plan says the rendering and referring providers are both 
OON providers and there was no approved authorization. Also, the service rendered was not urgent or 
emergent. 
 
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 laboratory services provided on August 2, 
2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from November 19, 
2021, to December 18, 2021. 
 
You asked the Plan to pay for the home health care services. You say that you would like the claim payment to 
be adjusted accordingly. The Plan denied your request. The Plan says the non-contracted provider did not 
submit the RAP claim for services for dates of service November 19, 2021, to December 18, 2021, until 
January 25, 2022. The Plan also says that no exception request was submitted to the Health Plan to waive the 5-
day requirement for filing the RAP claim due to a circumstance beyond the provider's control. 
 The Plan must follow Medicare rules. Medicare rules say that all HHAs must submit a RAP within 5 calendar 
days after the start of care date for initial 30-day periods and within 5 calendar days after the from date for 
each subsequent 30-day period of care. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days from the start of care date. Therefore, we decided that the Plan does not have to 
pay for the home health care services provided from November 19, 2021, to December 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection provided on July 21, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for infectious agent detection. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received 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 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 infectious agent detection provided on July 21, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment and supplies 
provided on March 4, 2022, to July 1st, 2022. 
 
You asked the Plan to waive the coinsurance for durable medical equipment and supplies. 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 15% 
coinsurance for durable medical equipment and related supplies.  
 
You have been asked to pay 15% coinsurance for durable medical equipment and supplies. This item/service 
falls within the durable medical equipment and related supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for durable medical equipment and supplies provided on March 4, 2022, to July 1st, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician visit services (G0402, G0463) billed for date of 
service May 26, 2022. 
 
You asked the Plan to pay for physician visit services. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT codes G0402 and G0463 is not supported in the case record. Specifically, a review of the file shows that the claim was not billed with condition code G0. Billing multiple medical visits in the same day 
requires this condition code. Based on this information, we decided that Medicare rules for coverage of 
physician visit services have not been met. Therefore, we decided that the Plan does not have to pay for 
physician visit services (G0402, G0463) billed for date of service May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the visual field examination (92083) 
provided on April 5, 2022. 
 
You asked the Plan to waive the copayment for the visual field examination. 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 
copay for the diagnosis and treatment of diseases and injuries of the eye under the Vision care benefit category.  
 
You have been asked to pay a $40 copay for the visual field examination. This item/service falls within the 
Vision 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 waive the copayment for the visual field 
examination (92083) provided on April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services provided on July 13, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for mental health services. You say that this should be covered and was medically 
necessary. The Plan denied your request. The Plan says there was no preauthorization by a primary care 
provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 mental health services provided on July 13, 2021, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
December 25, 2021, to January 29, 2022 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
services and 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 $350 
copayment for inpatient hospital care.  
 
You have been asked to pay a $350 copayment for inpatient hospital care. This item/service falls within the 
inpatient hospital 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 waive the copayment for inpatient 
hospital care provided from December 25, 2021, to January 29, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a follow up visit provided on July 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a follow up visit. You say that this should be covered. The Plan denied your 
request. The Plan says there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
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 a follow up visit provided on July 15, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on April 24, 2022, 
to April 25, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an inpatient admission was medically 
necessary. The Plan denied your request. The Plan says an inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the medical records did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on April 24, 2022, to April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), and sphere, trifocal lenses (V2301) 
provided on March 29, 2022. 
 You asked the Plan to pay for frames (V2020), and sphere, trifocal lenses (V2301). You say that you got two 
pairs of glasses because you needed two. The Plan denied your request. The Plan says you are responsible for 
this charge. The Plan also says that they have paid the maximum amount covered by your plan for this service. 
 
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 up to $230 every year for non-Medicare covered prescription eyewear. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover up to $230 every year for non-
Medicare covered prescription eyewear. The Plan rules also say that you are responsible for any amount above 
the $230. The record shows this benefit was exhausted on March 29, 2022. Based on this information, we 
decided that the Plan's rules for coverage of frames (V2020), and sphere, trifocal lenses (V2301) have not been 
met. Therefore, we decided that the Plan does not have to pay for frames (V2020), and sphere, trifocal lenses 
(V2301) provided on March 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection provided on July 14, 2022. 
 
You asked the Plan to waive the copayment for an injection. You say that you are requesting a reconsideration 
of 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 $350 
copayment for outpatient hospital services/Medicare-covered outpatient surgery.  
 
You have been asked to pay a $350 copayment for an injection. This item/service falls within the outpatient 
hospital services/Medicare-covered outpatient 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 injection provided on July 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan provided on May 13, 
2022, to June 8, 2022 , by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a CT scan. You say that you were unaware you needed to get an authorization for 
this visit. The Plan denied your request. The Plan says there was no preauthorization by a primary care provider 
(this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 a computed tomography (CT) scan provided on 
May 13, 2022, to June 8, 2022 , by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service November 
25, 2021. 
 
You asked the Plan to pay for procedure code 76700. You say that this should be paid for. 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 November 25, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on July 18, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy services. 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 psychotherapy services provided on July 18, 2022, 
by an out-of-network (OON) provider.