Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
15, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 11, 2022. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan of extremity veins provided on March 13, 
2023. 
 
You asked the Plan to pay for a duplex scan of extremity veins. You say that this service was 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 a duplex scan of 
extremity veins provided on March 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on March 16, 2023, to April 
27, 2023. 
 
You asked the Plan to pay for the laboratory service. 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 laboratory service 
provided on March 16, 2023, to April 27, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate cancer screening and the laboratory service 
provided on April 17, 2023. 
 
You asked the Plan to pay for the prostate cancer screening and the laboratory service. 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 prostate cancer 
screening and the laboratory service provided on April 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for five units of procedure code Q0092 rendered on May 19, 
2023. 
 
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 there was no specific rationale documented for the five x-rays. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code Q0092 is 2. The MAI value for this code is 3. You billed 5 units of this 
code, exceeding the MUE.  
 
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 Q0092. Our reviewer says that the services 
at issue in this case are not supported by the medical records. Our reviewer found that although the provided 
records in this do document that five different radiologic studies were performed on May 19, 2023, the records 
do not document any details that clarify why the additional services were reasonable and necessary in this case.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Q0092 have not been met. Therefore, we decided that the Plan does not have to 
pay for five units of procedure code Q0092 rendered on May 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis, aspiration and/or injection, major joint or 
bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance, Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), Hyaluronan or derivative, Synvisc or 
Synvisc-One, for intra-articular injection, 1mg provided on May 22, 2023. 
 
You asked the Plan to pay for arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, 
hip, knee, subacromial bursa); without ultrasound guidance, Fluoroscopic guidance for needle placement 
 (e.g., biopsy, aspiration, injection, localization device), Hyaluronan or derivative, Synvisc or Synvisc-One, for 
intra-articular injection, 1mg. You say that the services were medically necessary. The Plan denied your 
request. The Plan says that the member has no out-of-network benefits, no medical necessity for an  
out-of-network provider such as an urgent or emergency situation has been documented. There is no network 
deficiency for these services and alternate network providers were found. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for arthrocentesis, aspiration and/or injection, major joint or bursa 
(e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance, Fluoroscopic guidance for needle 
placement (e.g., biopsy, aspiration, injection, localization device), Hyaluronan or derivative, Synvisc or 
Synvisc-One, for intra-articular injection, 1mg provided on May 22, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services reported with DRG 180 rendered from 
September 1, 2022, to September 4, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you are 
appealing the partial recoupment of inpatient services. The Plan denied your request. The Plan says that the 
DRG was updated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 180. 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 the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were supported by the medical records. Our physician reviewer found that 
the enrollee presented with hypoxia and was found to have a large malignant pleural effusion. The enrollee was 
documented to require 2L nasal cannula for hypoxia. The enrollee had documented respiratory failure from 
pleural effusion requiring oxygen supplementation for hypoxia, so code J96.01 is supported. Documentation 
supports DRG 180 rather than 181. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services reported with DRG 180 rendered from September 1, 2022, to September 4, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an injection and diagnostic imaging of the 
retina provided on April 3, 2023. 
 
You asked the Plan to waive the cost share for an injection and diagnostic imaging. You say that you feel the 
cost share applied should be fully covered by the Plan. 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% 
coinsurance for Medicare Part B non-chemotherapy prescription drugs and a $20 copayment for Medicare-
covered outpatient diagnostic tests.  
 
You have been asked to pay $377.42 for an injection and diagnostic imaging. This total includes $357.42 
coinsurance, which is 20% of the allowed amount for an injection ($1,787.10 allowed x 20% = $357.42) and a 
$20 copayment for diagnostic imaging services. The injection falls within the Medicare Part B prescription 
drugs benefit category. The diagnostic imaging of the retina falls within the outpatient diagnostic tests 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 share for an injection and diagnostic imaging of the retina 
provided on April 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on May 2, 2023, and billed with codes 87900, 87799, 87798, 87652, 87640, 87500, and 87481. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on May 2, 2023, and billed with codes 87900, 87799, 87798, 87652, 87640, 87500, and 
87481.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the PET scan and cardiovascular stress test 
(A9555, J2785) provided on November 7, 2022. 
 
You asked the Plan to reduce the cost share for the PET scan and cardiovascular stress test (A9555, J2785). 
You say that you do not agree with the cost share amount you are being 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). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for each Medicare-covered Part B drug and nonchemotherapy drugs to treat cancer, 20% 
coinsurance for each Medicare-covered medical supply, 5% coinsurance for Medicare-covered non radiological 
diagnostic services. Examples include, but are not limited to EKGs, pulmonary function tests, home or lab-
based sleep studies, and treadmill stress tests and 5% coinsurance for Medicare-covered radiological diagnostic 
services, not including x-rays. 
 
You have been asked to pay a total of $317.73 for the PET scan and cardiovascular stress test (A9555, J2785).  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
November 7, 2022 PET scan $1,150.51 5% $57.53 
November 7, 2022 Cardiovascular 
stress test 
$58.54 5% $2.93 
November 7, 2022 Medical supply $1,040.46 20% $208.09 
November 7, 2022 regadenoson 
injection 
$245.92 20% $49.18 
TOTAL:    $317.73 
 
This item/service falls within the Medicare Part B prescription drugs, surgical supplies, other outpatient 
diagnostic tests - non-radiological diagnostic services and other outpatient diagnostic tests -Radiological 
diagnostic services, not including x-rays  benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the cost share 
for the PET scan and cardiovascular stress test (A9555, J2785) provided on November 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for knee orthotics provided on February 07, 
2023. 
 
You asked the Plan to waive the coinsurance for knee orthotics. You say that you say that you dont have 
enough money to pay and you only relying on your social security. 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% 
coinsurance for prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for knee orthotics. This item/service falls within the prosthetic 
devices 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. The total you owe is $175.47 ($877.36 allowed amount x 20% = $175.47). Therefore, we 
decided that the Plan does not have to waive the coinsurance for knee orthotics provided on February 07, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for EKG provided on April 11, 2023. 
 
You asked the Plan to waive the copayment for EKG. You say that you say that you are very weary and tired of 
the plans inability to do what they should do and to please take care of this. 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 and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for EKG. This item/service falls within the outpatient diagnostic tests and therapeutic services and 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. However, since the allowed amount is less than the standard copayment, 
you only owe $5.52. Therefore, we decided that the Plan does not have to waive the copayment for EKG 
provided on April 11, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each outpatient observation provided on 
February 03, 2023, to April 04, 2023. 
 
You asked the Plan to reduce the copayment for each outpatient observation. You say that you were admitted to 
inpatient status, not outpatient. 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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for each outpatient observation. This item/service falls within 
the emergency 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. The total amount you owe is $330 ($110 copayment x 3 observations). Therefore, we decided that 
the Plan does not have to reduce the copayment for each outpatient observation provided on February 03, 2023, 
to April 04, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care (99223) provided on March 9, 2023. 
 
You asked the Plan to pay for the inpatient care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 inpatient or observation care, per 
day, for the evaluation and management of a patient. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the records show a previous 
initial service billed. This was a subsequent instance. Based on this information, we decided that Medicare 
rules for coverage of the inpatient care have not been met. Therefore, we decided that the Plan does not have to 
pay for inpatient care (99223) provided on March 9, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency room (ER) visit (99285) provided on April 22, 2023. 
 
You asked the Plan to pay for the ER visit. You say that the services should be covered as you disagree with 
the charges, and you went to the correct hospital. The Plan denied your request. The Plan says that the services 
denied correctly as they were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for an emergency 
room (ER) visit (99285) provided on April 22, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on May 05, 2023. 
 
You asked the Plan to pay for the home visit. You say that the 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 the home visit provided 
on May 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the audiology services provided on March 03, 2023. 
 
You asked the Plan to pay for the audiology services. You say that you were not aware authorization was 
required. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the audiology services 
provided on March 03, 2023.