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

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service January 10, 
2023. 
 You asked the Plan to pay for procedure code 99213. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99213 is bundled into payment for code 90837. 
 
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 code 99213 
is a column II code to column I code 90837. 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 code 99213 billed for date of service January 10, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the carpal tunnel surgery provided on October 19, 2022. 
 
You asked the Plan to pay for the carpal tunnel surgery. You say that you are requesting reconsideration due to 
medical necessity. 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 carpal tunnel surgery 
provided on October 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a cataract removal procedure provided 
April 3, 2023, to April 10, 2023, by an out-of-network provider. 
 
You asked the Plan to waive the coinsurance for a cataract removal procedure. You say that you disagree with 
this coinsurance. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a 50% coinsurance for outpatient surgery/out-of-network.  
 
The enrollee has been asked to pay a 50% coinsurance of the allowed amount for a cataract removal procedure. 
The total allowed amount is $1,920.13. The total amount you are being asked to pay is $906.07 ($1,920.13 x 
50% = $960.07). This item/service falls within the outpatient surgery/out-of-network benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided 
that the Plan does not have to waive the coinsurance for a cataract removal procedure provided April 3, 2023, 
to April 10, 2023, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70470 billed for date of service April 3, 
2023. 
 You asked the Plan to pay for procedure code 70470. You say that 70470 should be paid as billed because it 
was not a bundled charge. The Plan denied your request. The Plan says payment for code 70470 is bundled into 
payment for code 70496. 
 
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 code 70470 
is a column II code to column I code 70496. 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 code 70470 billed for date of service April 3, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for  skilled nursing facility services provided 
on February 21, 2023 to March 31, 2023. 
 
You asked the Plan to waive the copayment for  SNF services. You say that you were told the care would be 
completely taken care of. 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 Days 1-
20 at $0 copay. Days 21 to 100 at $188 copay. You remain responsible for $2,202.38 which is less than the 
required copay for each date since the out-of-pocket maximum is met.  for Skilled Nursing Facility (SNF) Care.  
 You have been asked to pay $2,202.38.  Days 1-20 at $0 copay. Days 21 to 100 at $188 copay. You remain 
responsible for $2,202.38 which is less than the required copay for each date since the out-of-pocket maximum 
is met.  for SNF services. This item/service falls within the Skilled Nursing Facility (SNF) 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. Therefore, we 
decided that the Plan does not have to waive the copayment for  skilled nursing facility services provided on 
February 21, 2023 to March 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ostomy deodorant provided on March 28, 2023, by an out-of-
network (OON) provider.  
 
 You asked the Plan to pay for ostomy deodorant. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for ostomy deodorant provided on March 28, 2023, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, and an electrocardiogram (ECG) provided on 
January 17, 2023. 
 
You asked the Plan to pay for an office visit, and an electrocardiogram (ECG). You say that prior authorization 
is not required for these services. 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 an 
electrocardiogram (ECG) provided on January 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair.  
 
You asked the Plan to pay for a shower chair. You say that you would like reconsideration because the 
requested shower chair is medically necessary. The Plan denied your request. The Plan says this item is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a period oral evaluation (D0120), prophylaxis (D1110), 
amalgams (D2140/D2150), and resin-based composites (D2331), provided on October 5, 2021, to April 5, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says these services were processed correctly. 
 
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 D0120, D1110, and D2140/D2150 was exhausted on date of service November 8, 2021, 
October 6, 2022, and October 24, 2022. D2331 is not a covered benefit. Therefore, we decided that the Plan does not have to pay for a period oral evaluation (D0120), prophylaxis (D1110), amalgams (D2140/D2150), 
and resin-based composites (D2331), provided on October 5, 2021, to April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on September 14, 
2022, to September 23, 2022.  
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. 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 $225 
copayment each day for days 1 to 5 for Medicare-covered hospital care each time you are admitted. $0 
copayment for additional Medicare-covered days for inpatient hospital care. Includes inpatient acute, inpatient 
rehabilitation, long-term care hospitals, and other types of inpatient hospital services. Inpatient hospital care 
starts the day you are formally admitted to the hospital with a doctors order. The day before you are 
discharged is your last inpatient day. For the first five days there is a $225 each day. 5 x $225 = $1,125. 
Therefore, results in the total cost sharing amount of $1,125. 
 
You have been asked to pay a $225 copayment each day for inpatient hospital stay. This item/service falls 
within the inpatient hospital 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. Therefore, we decided that the Plan does not have to waive the copayment for 
inpatient hospital stay on September 14, 2022, to September 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient mental health stay provided 
from May 6, 2022, to May 27, 2022. 
 
You asked the Plan to waive the copayment for an inpatient mental health stay. You say that the service should 
be fully covered 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 $320 
copayment per day, for days 1 to 5 and a $0 copayment per day, for days 6 to 90 of an inpatient mental health 
stay. 
 
 You have been asked to pay a $320 copayment per day, for days 1 to 5 of the inpatient mental health stay. You 
have been asked to pay a total of $1,600 ($320 copayment x 5 days = $1,600). You have not been charged for 
any additional days. This item/service falls within the inpatient mental health 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. Therefore, we decided that the Plan 
does not have to waive the copayment for an inpatient mental health stay provided from May 6, 2022, to May 
27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dermatology appointment provided on November 22, 2022. 
 
You asked the Plan to pay for a dermatology appointment. You say that this is a yearly check. The office said 
that this would be covered in full. 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 dermatology 
appointment provided on November 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lab testing to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve lab testing. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
lab testing to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an inpatient hospital stay provided from 
April 11, 2023, to April 14, 2023. 
 
You asked the Plan to waive the cost share for an inpatient hospital stay. You say that you disagree with the 
cost share. 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 $250 deductible which applies to inpatient hospital care. Your 
contract with the Plan also clearly says that you must pay a $300 copayment per calendar year, after the 
deductible for covered services received in a general acute care hospital. 
 
 You have been asked to pay $250, which satisfied the deductible for the inpatient hospital care. The item or 
service you asked the Plan to waive the cost share for falls within the inpatient hospital care benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible which 
applies to inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time 
an inpatient hospital stay was received on April 11, 2023, to April 14, 2023. 
 
You have also been asked to pay a $300 copayment for the inpatient hospital stay. This item/service falls 
within the inpatient hospital care benefit category. You have been asked to pay a total of $550 ($250 deductible 
+ $300 copayment = $550). 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 inpatient hospital stay 
provided from April 11, 2023, to April 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process 
stabilization/distraction device. 
 
You asked the Plan to pre-approve the Vertiflex Superion Indirect Decompression System . You say that you 
have endured several years of severe lower back pain. You say your doctor is recommending this procedure. 
The Plan denied your request. The Plan says the Vertiflex Superion Indirect Decompression System is not 
medically necessary. The Plan says there is lack of evidence to support interspinous spacer devices as safe and 
effective as the gold standard of surgical decompression. 
 
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 the Vertiflex Superion Indirect 
Decompression System. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental, and more 
research needed 
 
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 Vertiflex Superion Indirect Decompression System have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous 
process stabilization/distraction device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 17, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and 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 an office visit provided 
on May 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the new patient office visit, and the office visit to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the office visits. You say that this is supported in the records. The Plan 
denied your request. The Plan says enrollees must receive their care from a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the new patient office visit, and the office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mechanical traction therapy provided on March 02, 2023, 
through March 16, 2023. 
 
You asked the Plan to pay for the mechanical traction therapy. You say that since being denied treatment you 
are now getting dizzy, and your balance is bad again. The Plan denied your request. The Plan says the only 
covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for mechanical traction therapy provided on March 02, 2023, through March 16, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of implant body (teeth 30 and 31) (D6105) and fixed 
partial denture sectioning (D9120) provided on March 22, 2023. 
 
You asked the Plan to pay for removal of implant body and fixed partial denture sectioning . You say that this 
should be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for removal 
of implant body (teeth 30 and 31) (D6105) and fixed partial denture sectioning (D9120) provided on March 22, 
2023.