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

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on 
December 05, 2022. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that you should not have a 
copayment for a mammogram. 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, including ultrasounds. 
 
You have been asked to pay a $20 copayment for the breast ultrasound. This item/service falls within the 
outpatient diagnostic tests, including ultrasounds 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 record shows you are only being charged a copayment for the 
ultrasound. Therefore, we decided that the Plan does not have to waive the copayment for the breast ultrasound 
provided on December 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telephone evaluation provided on February 02, 2023. 
 
You asked the Plan to pay for a telephone evaluation. You say that the services 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 telephone evaluation 
provided on February 02, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI) shows facet degenerative joint disease (djd) 
and stenosis. The cause of the back pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve the ESI. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESI when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using the same scale* for at least three months. 
 
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 ESI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found you have not had at least 50% pain relief for 
three months.  
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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the epidural steroid injection (ESI) (62323).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an iris prosthesis. 
 
You asked the Plan to pre-approve insertion of an iris prosthesis. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 insertion of an iris prosthesis. Our 
reviewer says that v Our physician reviewer found artificial iris devices are considered experimental and 
investigational for anterior segment reconstruction, and the treatment of aniridia and other iris defects because 
of insufficient scientific evidence of their safety and effectiveness. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an iris prosthesis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve insertion of an iris prosthesis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visit provided on December 14, 2022. 
 
You asked the Plan to pay for rest home visit. You say that you were not able to verify eligibility and obtain 
authorization. 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 December 14, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on December 3, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says this provider is not eligible to bill 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital.  
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Therefore, we decided that the Plan does not have to pay for the emergency room 
services provided on December 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation device provided on March 18, 2022, to 
May 18, 2022. 
 
You asked the Plan to pay for electrical stimulation device. You say that the services 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 electrical stimulation 
device provided on March 18, 2022, to May 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on 
December 26, 2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that the provider did nothing and 
you were only there for less than ten minutes and then you were sent to the emergency department without the 
provider at the urgent care addressing the medical issue you had. 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 urgently needed services.  
 
 You have been asked to pay a $50 copayment for the urgent care visit. This 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 urgent care visit 
provided on December 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and venipuncture services provided on 
November 14, 2022. 
 
You asked the Plan to pay for an office visit and venipuncture services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
venipuncture services provided on November 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the home health care visits provided from 
October 28, 2022, to February 15, 2023. 
 
You asked the Plan to waive the copayment for the home health care visits. You say that the services you 
receive are not worth the copayment amount. 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 2022 contract with the Plan clearly says that you must pay a 
$20 copayment for specialist services, including home health visits. Your 2023 contract with the Plan also clearly says that you must pay a $20 copayment for specialist services, including home health visits. 
 
You have been asked to pay a $20 copayment for each home health care visits. These items/services fall within 
the physician/practitioner services benefit category. You have been asked to pay a total of $80 ($20 copayment 
per visit x 4 visits = $80). 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 home health care visits 
provided from October 28, 2022, to February 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) machine 
provided on February 06, 2023. 
 
You asked the Plan to pay for a continuous positive airway pressure (CPAP) machine. You say that you called 
this facility and they said they took your Plan. 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 continuous positive 
airway pressure (CPAP) machine provided on February 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary complete denture (D5110) and mandibular 
immediate denture (D5140) provided on November 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that your provider informed you they are in-network 
with the Plan. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the maxillary complete denture (D5110) and mandibular immediate denture (D5140) provided on 
November 15, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for PT services provided from January 9, 2023, 
to January 26, 2023. 
 
You asked the Plan to waive the deductible for PT services. You say that you should not have to pay toward a 
deductible now since it did not apply to the previous appointments. 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. Your 
contract with the Plan says that there is a $400 deductible which applies to outpatient rehabilitation services.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient rehabilitation 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $400 deductible which applies to outpatient rehabilitation services. This cost sharing is a contractual 
obligation that had not been met at the time PT services were received on January 9, 2023, to January 26, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for PT services provided from 
January 9, 2023, to January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for heart monitor provided on January 05, 2023. 
 
You asked the Plan to pay for heart monitor. You say that you dont understand why the heart monitor test 
would not 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 heart monitor provided 
on January 05, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on August 25, 2022. 
 
You asked the Plan to pay for lab testing. You say that the test is a covered procedure that does not require 
authorization. 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 
August 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laparoscopy provided on November 22, 2022. 
 
You asked the Plan to pay for laparoscopy. You say that you are requesting the submitted documentation be 
reviewed. 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 laparoscopy provided on 
November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
November 16, 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 the documents do not support this level of care. 
 
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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
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 the provided records in this case 
do not document 2 out of 3 of an extensive number of diagnoses or management options, an extensive amount 
and complexity of data reviewed and high risk of complication. 
 
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 initial hospital care (procedure code 99223) rendered on November 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
November 20, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you feel this copayment 
is too high and want it 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 $300 
copayment for on-way ambulance services. 
 
You have been asked to pay a $300 copayment for the ambulance services. This item/service falls within the 
on-way 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 November 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit provided on December 12, 2022. 
 
You asked the Plan to pay for a rest home visit. You say that the services 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 rest home visit 
provided on December 12, 2022.