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

 
We decided that the Plan does not have to waive the copayment for an in-network urgent care visit provided on 
May 13, 2023. 
 
You asked the Plan to waive the copayment for an in-network urgent care visit. You say that you were 
misdiagnosed by the provider at this facility. You do not feel you should have to pay this 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 $60 
copayment for urgently needed services. 
 
You have been asked to pay a $60 copayment for an in-network urgent care visit. This item/service falls within 
the urgently needed 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 in-
network urgent care visit provided on May 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the influenza vaccine (90682) and administration (G0008) 
provided on June 2, 2022. 
 
You asked the Plan to pay for the immunization services. You say that this claim was filed timely. The Plan 
denied your request. The Plan says the claim was not filed within one calendar year of the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the immunization services was not filed until June 14, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the influenza vaccine (90682) and administration (G0008) 
provided on June 2, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan of extracranial arteries (93880). 
 
You asked the Plan to pre-approve a duplex scan of extracranial arteries. You say that it is very important that 
you have this service as you are scared for your health. The Plan denied your request. The Plan says the 
requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that peripheral artery studies may be considered medically 
necessary if the signs and symptoms listed in the Medicare rules section of this letter are present. 
 
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 pre-approve a duplex scan of extracranial arteries. 
Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found that you have 
has no carotid bruits and no history of cerebral vascular accident (CVA), transient ischaemic attack (TIA), or 
headaches. Our reviewer also found that you have no signs or symptoms of Peripheral Arterial disease and 
would not benefit from this non-invasive study. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a duplex scan of extracranial arteries have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a duplex scan of extracranial arteries (93880).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), a cleaning (D1110), 
a crown (D2740), and the core buildup (D2950) for tooth #12 provided by an out-of-network provider on June 
12, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you received a bill and would like the Plan 
to cover the dental services. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
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 total amount billed for the periodic oral evaluation was $69 and the total allowed amount was $23 leaving 
a difference of $46 ($69 billed - $23 allowed). The total amount billed for the cleaning was $122 and the total 
allowed amount was $49 leaving a difference of $73 ($122 billed - $49 allowed). The total amount billed for 
the crown was $1,573 and the total allowed amount was $679 leaving a difference of $894 ($1,573 billed - 
$679 allowed). The total amount billed for the core buildup was $375 and the total allowed amount was $153 
leaving a difference of $222 ($375 billed - $153 allowed). 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a periodic oral evaluation (D0120), a 
cleaning (D1110), a crown (D2740), and the core buildup (D2950) for tooth #12 provided by an out-of-network 
provider on June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a craniectomy/craniotomy procedure (61312-76) provided on 
March 24, 2023. 
 
You asked the Plan to pay for 61312-76. You say that this service was medically necessary. The Plan denied 
your request. The Plan says this is considered as being part of the global surgical package of the initial 
procedure 61312 billed by the same provider on date of service March 23, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat procedures performed by the same 
physician are not separately paid, and the Medicare contractor may not make adjustments in the fee schedule 
amount for codes billed with modifier -76.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of 61312-76 have not been met. Therefore, we decided that the Plan does not have to pay for a 
craniectomy/craniotomy procedure (61312-76) provided on March 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires an LTACH level of 
care and is stable for discharge to that level of care. The Plan denied your request. The Plan says the enrollee 
does not meet the guidelines for care in an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in the current acute care setting as provided 
by the Plan. The documentation does not support that LTACH services are medically appropriate at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee clearly exceeds the CMS 
established defining criteria for an appropriate LTACH admission. The Plan denied your request. The Plan says 
the enrollee does not meet the guidelines for care in an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the Plan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 9, 2023, to June 
10, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the claim form does not have 
the appropriate home health data to process and pay the claim. The claim must have the appropriate type of bill 
to process. 
 
The Plan follows Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of home health services have not been met. The claim was billed  
with an invalid type of bill. We find the Medicare rule for payment of this June 9, 2023, through June 10, 2023, 
claim has not been met. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from June 9, 2023, to June 10, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on June 
02, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you did not order this 
ambulance yourself. 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 $260 
copayment for ambulance services. 
 
You have been asked to pay a $260 copayment for the ambulance services. 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 copayment for the ambulance 
services provided on June 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital inpatient or observation care, 75 minutes must 
be met or exceeded (99223) and subsequent hospital inpatient or observation care, 50 minutes must be met or 
exceeded (99233) provided on March 28, 2022, to March 29, 2022. 
 
You asked the Plan to pay for hospital services. You say that you disagree with the denial and have submitted 
medical records for review. The Plan denied your request. The Plan says codes 99223 and 99233 remain not 
supported. The medical records submitted for both codes do not support high level of medical decision making 
or total time required of the codes billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 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 hospital services. Our reviewer says that the service does not 
meet criteria for payment on this claim. Our reviewer found the criteria to report the codes in question is not 
present in the medical record. The record contains documentation of a brief interval history and moderate 
medical decision making (medication management, monitoring current treatment). 2 out of the 3 key 
components of 99223 are not present. The record does not contain documentation of high medical decision 
making. The medical decision making includes monitoring the patient, continuing medications, and adding new 
medications. Medication management is considered moderate medical decision making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hospital services have not been met. Therefore, we decided that the Plan does 
not have to pay for initial hospital inpatient or observation care, 75 minutes must be met or exceeded (99223) 
and subsequent hospital inpatient or observation care, 50 minutes must be met or exceeded (99233) provided 
on March 28, 2022, to March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on June 
01, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you were seen by a 
nurse practitioner and should only have to pay a $5 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 $40 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $40 copayment for the specialist office visit. This item/service falls within the 
in-network specialist physician/practitioner 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. The Plan contract says that treatment by a nurse practitioner or 
physicians assistant or other non-physician health care professionals during a specialists office or telehealth 
visit will apply up to a $40 copay. Therefore, we decided that the Plan does not have to waive the copayment 
for the specialist office visit provided on June 01, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on December 8, 2022, to 
January 6, 2023. 
 You asked the Plan to pay for home health services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 8, 2022. The NOA was not received by the Plan until March 1, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
on December 8, 2022, to January 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit provided on June 27, 2023. 
 
You asked the Plan to pay for the telehealth visit. You say that you are requesting reconsideration of the denied 
claim. 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 telehealth visit 
provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the out-of-network physician services 
provided on February 8, 2023. 
 
You asked the Plan to waive the cost share for the out-of-network services. You say that the enrollee is being 
balance billed. 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 50% of the allowed amount for out-of-network physician services.  
 
The enrollee has been asked to pay 50% of the allowed amount for the out-of-network services. The services 
fall within the physician 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 cost share for the out-of-network physician services 
provided on February 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery (D4261), a bone replacement graft (D4263) 
and guided tissue regeneration (D4266) provided on March 28, 2023. 
 
You asked the Plan to pay for osseous surgery (D4261), a bone replacement graft (D4263) and guided tissue 
regeneration (D4266). You say that this was not an elective oral surgery, but a necessary procedure to stabilize 
one quadrant of your mouth. The Plan denied your request. The Plan says these services are not covered under 
your contract under any normal circumstances. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for osseous 
surgery (D4261), a bone replacement graft (D4263) and guided tissue regeneration (D4266) provided on March 
28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on June 21, 2023. 
 
You asked the Plan to pay for the home visit. You say that you are requesting reconsideration of the denied 
claim. 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 home visit provided 
on June 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and an annual wellness visit provided on May 
4, 2023, by an OON provider.  
 
You asked the Plan to pay for an office visit and an annual wellness visit. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says the service was not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 an office visit and an annual wellness visit 
provided on May 4, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit for the evaluation and 
management of an established patient (99214) provided on March 22, 2023. 
 
You asked the Plan to pay for an office visit. You say that the records describe the services rendered and need 
for medical necessity. The Plan denied your request. The Plan says code 99214 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. 
 
 
 
 
 
 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 an office visit. Our reviewer says that the service does not 
meet criteria for payment on this claim. Our reviewer found evaluation and management procedure for date of 
service billed, supports a low complexity medical decision making, which includes limited number of 
diagnoses; limited complexity of data reviewed; low risk of complications. There is a more specific code to 
report for service provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for an office or other outpatient visit for the evaluation and management of an established patient 
(99214) provided on March 22, 2023.