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

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on August 11, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you told the hospital to put 
the enrollee on a shuttle bus which would have been significantly less. 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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for 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 ambulance services 
provided on August 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for Myocardial imaging, positron emission 
tomography (PET) provided on July 20, 2023. 
 
You asked the Plan to reduce the copayment for Myocardial imaging, positron emission tomography (PET). 
You say that your copayment should be $20. 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 $180 
copayment for advanced imaging services. 
 
You have been asked to pay a $180 copayment for Myocardial imaging, positron emission tomography (PET). 
This item/service falls within the advanced imaging 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 reduce the copayment for Myocardial imaging, positron emission tomography (PET) provided on July 20, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency care services provided on 
August 01, 2023. 
 
You asked the Plan to waive the copayment for the emergency care services. You say that you were never seen 
by the provider. 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 $125 
copayment for emergency care. 
 
You have been asked to pay a $125 copayment for the emergency care services. 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. However, since the allowed amount is less than the standard copayment, you only owe $74.27. 
Therefore, we decided that the Plan does not have to waive the copayment for the emergency care services 
provided on August 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lymphadenopathy therapeutic massage provided on June 
01, 2023, to June 29, 2023. 
 
You asked the Plan to pay for the lymphadenopathy therapeutic massage. You say that that you doctor 
provided a letter stating that this medical service is needed. 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 lymphadenopathy 
therapeutic massage provided on June 01, 2023, to June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement procedure provided on May 19, 2023. 
 
You asked the Plan to pay for the debridement procedure. 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 debridement 
procedure provided on May 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on February 14, 2023, to June 6, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the provider told you they accepted your 
insurance, and the services would be covered. 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 dental services provided on February 14, 2023, to June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93041 for date of service December 28, 
2022. 
 
You asked the Plan to pay for procedure code 93041. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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 find that CPT code 93041 is not payable as billed. Specifically, code 93041 is assigned a Q1 indicator 
(Packaged APC payment if billed on the same claim as a HCPCS code assigned status indicator S, T, or 
V"). CPT code 99285 was assigned final status indicator V since the APC assigned was 5025. This service 
billed is not separately payable. Based on this information, we decided that Medicare rules for coverage of 
procedure code 93041 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 93041 for date of service December 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service April 13, 
2023.   
You asked the Plan to pay for procedure code 88341. You say that you disagree with the Plan's denial. 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 88341 is 13. The MAI value for this code is 3. You billed 15 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service April 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87491, 87563, 87640, 87653, and 
87798 for date of service August 4, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87491, 87563, 87640, 87653, and 87798. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the amplified probe 
technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were used in 
this case. As such, a single code with one unit of service should be used. Based on this information, we decided 
that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 87481, 87491, 87563, 87640, 87653, and 87798 for date of service 
August 4, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on July 
20, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you already paid this 
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 $275 
copayment for ambulance services. 
 
You have been asked to pay a $275 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. However, since the allowed amount is less than the standard copayment, you only owe $269.33. 
Therefore, we decided that the Plan does not have to waive the copayment for the ambulance services provided 
on July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223 and 99232 for date of service August 
6, 2023, to August 9, 2023. 
 
You asked the Plan to pay for procedure codes 99223 and 99232. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the codes at issue are 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. 
 
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, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded.  
The CPT Code Manual definition of code 99232 is subsequent hospital inpatient or observation care, per day, 
for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded. 
 
We find that CPT codes 99223 and 99232 are not supported in the medical record. Specifically, the codes 
definition is time-based, and the records submitted for review do not document the total time spent providing 
the services described by these codes. Based on this information, we decided that Medicare rules for coverage 
of procedure codes 99223 and 99232 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 99223 and 99232 for date of service August 6, 2023, to August 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 14, 2023. 
 
You asked the Plan to pay for an office 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 an office visit provided 
on July 14, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 14, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you should not be responsible 
to pay this because you were not taken to the hospital you requested and you were given incorrect information 
regarding additional ambulance services. 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 
$250.00 copayment for ambulance services.  
You have been asked to pay a $250.00 copayment for 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 ambulance services 
provided on May 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit (99212) provided on June 14, 2023. 
 
You asked the Plan to pay for a specialist office visit (99212). You say that you are appealing with supporting 
records. 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 specialist office visit 
(99212) provided on June 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI)-joint 
upper extremity provided on June 07, 2023. 
 
You asked the Plan to waive the copayment for magnetic resonance imaging (MRI)-joint upper extremity. You 
say that you are appealing the copayment applied. 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 
$229.51 copayment for MRI. 
 
You have been asked to pay a $229.51 copayment for magnetic resonance imaging (MRI)-joint upper extremity. This item/service falls within the MRI 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. This is less than the standard $275 copayment amount. Therefore, 
we decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI)-joint 
upper extremity provided on June 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit (99214) provided on October 25, 
2022. 
 
You asked the Plan to pay for a specialist office visit (99214). You say that you are appealing with supporting 
records. 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 specialist office visit 
(99214) provided on October 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance services provided on July 08, 
2023. 
 
You asked the Plan to pay for non-emergency ambulance 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 non-emergency 
ambulance services provided on July 08, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug 
classes (G0482) provided on April 12, 2023. 
 
You asked the Plan to pay for the definitive UDT for 15-21 drug classes. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says ordering a multi-class panel of definitive 
(confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that definitive UDT is covered when the criteria in the 
rules section of this letter are met. 
 
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 definitive UDT for 15-21 drug classes. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found that there is no 
history of self-escalation, early refills or evidence of abuse. There was no indication for definitive testing. The 
testing was not medically reasonable and necessary. 
 
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 definitive UDT for 15-21 drug classes have not been met. Therefore, we 
decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug classes 
(G0482) provided on April 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 04, 2023. 
 
You asked the Plan to pay for the genetic testing. 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 genetic testing 
provided on May 04, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for psychotherapy provided from July 6, 2023, to 
July 25, 2023. 
 
You asked the Plan to reimburse you for the psychotherapy. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
psychotherapy provided from July 6, 2023, to July 25, 2023.