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

 
We decided that the Plan does not have to waive the copayments for ambulance, emergency room services and 
urgent care on October 23, 2022, to November 20, 2022.  
 
You asked the Plan to waive the copayments for ambulance, emergency room services and urgent care. You 
say that you believe you should be charged for an inpatient stay. 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 per trip for ambulance services. Copayment waived if admitted. Covered ambulance services 
include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can 
provide care if they are furnished to a member whose medical condition is such that other means of 
transportation could endanger the persons health or if authorized by the plan. You must pay a $90 copayment 
per visit for emergency care. You are not required to pay the emergency room copay if you are admitted to the 
hospital as an inpatient for the same condition within 3 days of an emergency room visit. Emergency care 
refers to services that are furnished by a provider qualified to furnish emergency services and needed to 
evaluate or stabilize an emergency medical condition. You must pay $30 copayment per visit for urgent care. 
Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury, or 
condition that requires immediate medical care. Urgently needed services may be furnished by network 
providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible. 
$300 + $90 + $90 + $30 = $510. Therefore, results in the total cost sharing amount of $510. 
 
You have been asked to pay a $300 copayment for ambulance, a $90 copayment for each emergency room 
service and a $30 copayment for urgent care. This item/service falls within the ambulance services, emergency 
care and 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 copayments for 
ambulance, emergency room services and urgent care on October 23, 2022, to November 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the weight loss management program 
(A9270) purchased on January 1, 2022. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered 
benefit.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.   
 
The Plans rules for coverage of the weight loss management program purchased in this case have not been met 
because you have not submitted proof of payment to the Plan for fees incurred for membership in this program. 
The receipt provided to the Plan was for food purchased for this program. The weight loss management benefit 
does not cover costs for pre-packed meals/food.   
 
 
 
Therefore, we decided that the Plan does not have to issue reimbursement for the weight loss management 
program (A9270) purchased on January 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on November 14, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that the services rendered 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 nursing facility care 
provided on November 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the lower limb prosthesis, and related 
supplies provided on July 8, 2022. 
 
You asked the Plan to waive the cost sharing for the lower limb prosthesis, and related supplies. You say that 
you do not want to be responsible for the coinsurance 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 contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare-covered prosthetic devices, supplies related to prosthetic devices, and orthotics. 
 
 You have been asked to pay a $1035.19 coinsurance for the lower limb prosthesis, and related supplies 
($5175.99 allowed amount x .20 = $1035.19 rounded down). These items/services fall 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. Therefore, we decided that the Plan does not have to waive the cost sharing for the lower 
limb prosthesis, and related supplies provided on July 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nutritional formula (B4185, B4193, B4199 B4220, 
B4224). 
 
You asked the Plan to pre-approve the nutritional formula. You say that this item is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that for parenteral nutrition to be considered reasonable 
and necessary, the treating practitioner must document that enteral nutrition has been considered and ruled out, 
tried and been found ineffective, or that enteral nutrition exacerbates gastrointestinal tract dysfunction. The 
beneficiary must have a condition involving the small intestine and/or its exocrine glands which significantly 
impairs the absorption of nutrients, or a disease of the stomach and/or intestine which is a motility disorder and 
impairs the ability of nutrients to be transported through and absorbed by the gastrointestinal (GI) system. 
 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 nutritional formula. Our reviewer 
says that the parenteral nutritional formula is not medically necessary. Our physician reviewer found records do 
not show that enteral nutrition has been tried and found ineffective. 
 
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 nutritional formula have not been met. Therefore, we decided that the Plan 
does not have to pre-approve nutritional formula (B4185, B4193, B4199 B4220, B4224).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail debridement provided on February 08, 2023. 
 
You asked the Plan to pay for nail debridement. You say that you are appealing the claim payment denial. 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 nail debridement 
provided on February 08, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail debridement provided on March 22, 2023. 
 
You asked the Plan to pay for nail debridement. You say that you are appealing the claim payment denial. 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 nail debridement 
provided on March 22, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on February 05, 
2023. 
 
You asked the Plan to pay for outpatient mental health services. You say that these services are 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 outpatient mental health 
services provided on February 05, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on February 16, 2023. 
 
You asked the Plan to pay for skilled nursing services. You say that you are appealing the claim payment 
denial. 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 skilled nursing services 
provided on February 16, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an emergency room visit provided on 
April 06, 2023. 
 
You asked the Plan to reduce the copayment for an emergency room visit. You say that this was an urgent care 
visit. 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 in and out-of-network emergency department visits. 
 
You have been asked to pay a $110 copayment for an emergency room visit. This item/service falls within the 
in and out-of-network emergency department visits benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the 
copayment for an emergency room visit provided on April 06, 2023.
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 
March 21, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not have a 
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 $35 
copayment for in-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
in-network physician/practitioner services, including doctors office visits benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the specialist office visit provided on March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 31, 2023. 
 
You asked the Plan to pay for dental services. You say that this should be covered. The Plan denied your 
request. The Plan says you were not enrolled in the dental plan on the date of service. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. If you would like possible coverage, please send to your new plan. Therefore, we decided that 
the Plan does not have to pay for dental services provided on January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shingles vaccine provided on September 28, 2022. 
 
You asked the Plan to pay for shingles vaccine. You say that it is medically necessary. The Plan denied your 
request. The Plan says it is not medically necessary. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to shingles vaccine. 
Therefore, we decided that the Plan does not have to pay for shingles vaccine provided on September 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail trimming provided on March 15, 2023. 
 
You asked the Plan to pay for nail trimming. You say that you are appealing the claim payment denial. 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 nail trimming provided 
on March 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, & 87653 billed for 
date of service December 28, 2022. 
 You asked the Plan to pay for procedure codes 87150, 87481, 87641, & 87653. You say that these services 
were medically necessary. The Plan denied your request. The Plan says payment for codes 87150, 87481, 
87641, & 87653 is bundled into payment for codes 87500 & 87801. 
 
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 codes 
87150, 87481, 87641, & 87653 are column II codes to column I codes 87500 & 87801. 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 codes 87150, 87481, 
87641, & 87653 billed for date of service December 28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for speech therapy provided on December 19, 2022. 
 
You asked the Plan to pay for speech therapy. You say that you are appealing the claim payment denial. 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 speech therapy provided 
on December 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) 
provided on March 15, 2023. 
 
You asked the Plan to waive the copayment for magnetic resonance imaging (MRI). You say that the 
copayment is too expensive and you would like 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 $150 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $150 copayment for magnetic resonance imaging (MRI). 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. Therefore, we decided that the Plan 
does not have to waive the copayment for magnetic resonance imaging (MRI) provided on March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tetanus, Diphtheria, and acellular Pertussis vaccine provided 
on February 13, 2023. 
 
You asked the Plan to pay for Tetanus, Diphtheria, and acellular Pertussis vaccine. You say that it is medically 
necessary. The Plan denied your request. The Plan says it is not a covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus, Diphtheria, 
and acellular Pertussis vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Tetanus, 
Diphtheria, and acellular Pertussis vaccine. Therefore, we decided that the Plan does not have to pay for 
Tetanus, Diphtheria, and acellular Pertussis vaccine provided on February 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88360 billed for date of service June 28, 
2022.   
You asked the Plan to pay for procedure code 88360. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
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 88360 is 6. The MAI value for this code is 3. You billed 8 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 
88360 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88360 
billed for date of service June 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound on December 21, 2022.  
 
You asked the Plan to waive the copayment for ultrasound. You say that why should you have to pay so much 
for this service and that the insurance should pay for it. 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 $105 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic). Covered services 
include but are not limited to other outpatient diagnostic tests - Radiological diagnostic services, not including x-rays. The provider billed in the amount of $444 and the allowed amount is $82.75. This is less than the 
copayment amount. You stated you paid $15 on the date of service; this has been taken off your overall bill. 
$82.75 - $15 = $67.75. Therefore, results in the total cost sharing amount of $67.75. 
 
You have been asked to pay a $67.75 copayment, which is less than the copayment for ultrasound. 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. Therefore, we decided that 
the Plan does not have to waive the copayment for ultrasound on December 21, 2022.