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

 
We decided that the Plan does not have to waive the copayment for an office visit provided on February 20, 
2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that services were not provided. 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 $30 
copayment for in-network urgently needed telehealth services. 
 
You have been asked to pay a $30 copayment for an office visit. This item/service falls within the in-network 
urgently needed telehealth services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an office visit provided on February 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance provided on December 06, 
2022. 
 
You asked the Plan to waive the copayment for ambulance. 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 $300 
copayment for ambulance services. 
 
You have been asked to pay a $300 copayment for ambulance. 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 provided on 
December 06, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on September 28, 2022, and 
billed with codes 87481, 87500, 87511, 87640, 87653, and 87798. 
 
You asked the Plan to pay for the laboratory testing. 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 laboratory testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on September 28, 
2022, and billed with codes 87481, 87500, 87511, 87640, 87653, and 87798.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the group 3 standard power wheelchair with single 
power option (K0856), power seating system, tilt only (E1002), retractable or removable mounting hardware 
for joystick (E1028 x2), electronic connection between wheelchair controller and one power seating system 
motor (E2310), cushioned headrest (E0955), skin protection and positioning wheelchair seat cushion (E2608), 
and positioning wheelchair back cushion (E2620).  
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the enrollee requires a 
power chair for mobility and would benefit from a power chair with the requested features to maximize their 
independence in the community, decrease skin risk, and decrease risk of falls.  The Plan denied your request. 
The Plan says  the submitted information does not document specific mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing that use of a power wheelchair will 
significantly improve the enrollee's ability to participate in MRADLs. The Plan also says a swing away joystick 
(E1028) is not documented to be necessary for slide transfer.  
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 durable medical equipment (DME). 
Our physician reviewer found it is not clear how the device will assist you with Mobility-Related Activities of 
Daily Living (MRADL) and why the device is necessary when there are caregivers who can provide 
compensatory support. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the group 3 standard power wheelchair with single power 
option (K0856), power seating system, tilt only (E1002), retractable or removable mounting hardware for 
joystick (E1028 x2), electronic connection between wheelchair controller and one power seating system motor 
(E2310), cushioned headrest (E0955), skin protection and positioning wheelchair seat cushion (E2608), and 
positioning wheelchair back cushion (E2620).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of procedure code 99458 rendered on 
March 30, 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 rationale given for the additional units.  
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 99458 is "Remote physiologic monitoring treatment 
management services, clinical staff/physician/other qualified health care professional time in a calendar month 
requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes 
(List separately in addition to code for primary procedure)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee has diabetes and 
received monitoring and counseling. There is no clear documentation that supports the additional unit of CPT 
99458. There is no evidence of why these additional services would be medically necessary. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for an additional unit of procedure code 99458 rendered on March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 9, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the Plan requires utilization of network providers when 
possible and available and requires authorization for certain services. No medical necessity for an  
out-of-network provider such as an urgent or an emergent situation that has been documented. 
 
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 subsequent nursing facility care provided on January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a lightweight wheelchair provided on 
January 25, 2023. 
 
You asked the Plan to waive the coinsurance for a lightweight wheelchair. You say that you never received this 
item. 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 all other covered durable medical equipment (DME) items. 
 
You have been asked to pay 20% coinsurance for a lightweight wheelchair. This item/service falls within the 
all other covered durable medical equipment (DME) items 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 $14.30 ($71.51 allowed 
amount x 20% = $14.30). Therefore, we decided that the Plan does not have to waive the coinsurance for a 
lightweight wheelchair provided on January 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 07, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support the services 
provided. 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 laboratory services 
provided on February 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for office visits on March 27, 2023, to April 
06, 2023. 
 
You asked the Plan to waive the copayments for office visits. 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 $35 
copayment for each in-person specialist visit. Covered services include consultation, diagnosis, and treatment 
by a specialist. There were two visits. 2 x $35 = $70. Therefore, results in the total cost sharing amount of $70. 
 
 
 You have been asked to pay a $35 copayment for each office visit. This item/service falls within the 
physician/practitioner services, including doctor's 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 copayments for office visits on March 27, 2023, to April 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on February 23, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and to obtain authorization. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a nursing facility visit 
provided on February 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 21, 2022. 
 
You asked the Plan to pay for the 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 the office visit provided 
on September 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for extremity brace on June 20, 2022.  
 
You asked the Plan to waive the coinsurance for extremity brace. 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 20% 
coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies. Covered items 
include, but are not limited to wheelchairs, crutches, powered mattress systems, diabetic supplies, hospital bed 
ordered by a provider for use in the home, IV infusion pumps, speech generating devices, oxygen equipment, 
nebulizers, and walkers. The provider billed in the amount of $278.15 and the allowed amount is $234.34 for 
the service. $234.34 x 20% = $46.87. Therefore, results in the total cost sharing amount of $46.87. You have been asked to pay a 20% coinsurance for extremity brace. This item/service falls within the durable 
medical equipment (DME) 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 
coinsurance for extremity brace on June 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
January 16, 2023, to January 20, 2023. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you are not responsible 
for the 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 $275 
copayment per day, for days 1 to 6 and a $0 copayment per day, for days 7 to 90 for each in-network medically 
necessary covered inpatient stay.  
 
 You have been asked to pay a $275 copayment per day, for days 1 to 4 of the inpatient hospital stay. The total 
amount you owe is $1,100 ($275 copayment x 4 days = $1,100). You have not been charged for any additional 
days. This item/service falls within the inpatient services in a psychiatric hospital 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 hospital stay provided from January 16, 2023, to January 
20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the administration of the injections 
provided from January 4, 2023, to March 13, 2023. 
 
You asked the Plan to waive the copayment for the administrations. You say that you think that the copayments 
are incorrect. 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 Medicare-covered surgical services performed in an outpatient department of a hospital. 
 
 You have been asked to pay a $367.20 copayment for the administrations because the allowed amount for each 
service is less than the $275 copayment. These items/services fall within the outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers 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 administration of the injections provided from January 4, 2023, 
to March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the specialist office visit and the knee 
injection drug provided on May 22, 2022. 
 
You asked the Plan to reduce the cost share for the specialist office visit and the injection drug. You say that 
you have been charged incorrectly. 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 $45 
copayment for in-network provider and professional services in a specialist's office. Your contract with the 
Plan also clearly says that you must pay 20% coinsurance for Medicare Part B covered drugs. 
 
You have been asked to pay a $45 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services, including doctor's 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. 
 
You have also been asked to pay $200.45, which is 20% coinsurance of the allowed amount for the knee 
injection drug ($1,002.24 allowed amount x 20% = $200.45). This item/service falls within the Medicare Part 
B prescription drugs 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 
specialist office visit and the knee injection drug provided on May 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Computed tomography, thorax, diagnostic; without 
contrast material (71250).  
 
You asked the Plan to pre-approve a Computed tomography. The Plan denied your request. The Plan says the 
enrollee is 81 years of age and does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 a Computed tomography. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found a computed tomography chest 
for lung cancer screening has been denied absent fulfillment of all necessary criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Computed tomography have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Computed tomography, thorax, diagnostic; without contrast material 
(71250).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81455 for date of service January 20, 2023. 
 
You asked the Plan to pay for procedure code 81455. 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. 
 
We find that CPT code 81455 is not supported in the medical record. Specifically, the date of service billed is 
January 20, 2023. However, the date of service does not align with the records. The collection date was 
December 15, 222, the received date was January 11, 2023, and the date signed/reported was January 19, 2023. 
Based on this information, we decided that Medicare rules for coverage of procedure code 81455 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 81455 for date of service 
January 20, 2023.