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

 
We decided that the Plan does not have to waive the copayment for in-network wound care services provided 
on February 23, 2023. 
 
You asked the Plan to waive the copayment for in-network wound care services. You say that you did not have 
surgery, this was a follow up 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 $175 
copayment for Medicare-covered services provided in an outpatient hospital. 
 
You have been asked to pay a $175 copayment for in-network wound care services. This item/service falls 
within the Medicare-covered services provided in an outpatient 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 in-network wound care services provided on February 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the catheter placement, the ECG, and the laboratory services 
provided on March 6, 2023, by an OON provider.  
 
You asked the Plan to pay for the catheter placement, ECG, and lab services. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says these services are not 
covered when received out-of-network. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that out-of-network outpatient diagnostic testing and procedures are not covered. 
 
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 the catheter placement, the ECG, and the 
laboratory services provided on March 6, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 28, 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 October 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic sigmoidoscopy provided on 
March 29, 2023. 
 
You asked the Plan to waive the copayment for a diagnostic sigmoidoscopy. You say that you do not 
understand the copayment applied to this service. 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 each in-network Medicare-covered outpatient hospital facility visit. 
 
You have been asked to pay a $250 copayment for a diagnostic sigmoidoscopy. This item/service falls within 
the each in-network Medicare-covered outpatient hospital facility visit 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 a diagnostic sigmoidoscopy provided on March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a new patient office visit provided on 
February 11, 2023. 
 
You asked the Plan to waive the copayment for a new patient office visit. You say that the provider did not 
treat you. 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 $40 
copayment for each Medicare-covered urgent care visit. 
 
You have been asked to pay a $40 copayment for a new patient office visit. This item/service falls within the 
each Medicare-covered urgent care visit 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 a new patient office visit provided on February 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for prostate exam on January 21, 2023. 
 
You asked the Plan to waive the copayment for prostate exam. 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 $0 
copayment for each Medicare covered digital rectal exam. For men aged 50 and older, covered services include 
the following once every 12 months digital rectal exam and Prostate Specific Antigen (PSA) test. The 2023 
Schedule of Cost Sharing clearly states that enrollee is entitled to the PSA test once every 12 months: year. The 
enrollee would not be eligible until the 12month timeframe has passed, March 1, 2023. The provider billed in 
the amount of $148.48. Therefore, results in the total cost sharing amount of $148.48. 
 You have been asked to pay a $148.48 copayment for prostate exam. This item/service falls within the prostate 
cancer screening exams 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 prostate 
exam on January 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee surgery provided on February 10, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the knee surgery. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the service was not authorized. 
 
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 a knee surgery provided on February 10, 2023, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223, & 99233 provided on August 25, 
2022 to August 28, 2022.   
You asked the Plan to pay for procedure codes 99223, & 99233. You say that these services were medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital care for the evaluation and 
management of a patient, requiring a comprehensive history, a comprehensive examination and medical 
decision making of high complexity. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the medical records 
submitted did not support a comprehensive history. Code 99233 is including in the 90 day global surgery 
period of major procedure code 27590 and is not separately payable. Based on this information, we decided 
that Medicare rules for coverage of procedure codes 99223, & 99233 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99223, & 99233 provided on August 25, 2022 to August 
28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee has short-term memory difficulty 
and requires assistance with medication, transportation, and finances. The Plan denied your request. The Plan 
says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee is not noted to have both AD 
and FTD. There was some suspicion of AD, but there's no mention of FTD in the records. The request would 
not meet Medicare criteria for coverage at this time. 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the therapeutic phlebotomy services 
provided on March 22, 2023. 
 
You asked the Plan to waive the copayment for the therapeutic phlebotomy services. You say that this is not 
the correct 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 $250 
copayment for surgery services provided at an outpatient hospital. 
 
 
 You have been asked to pay a $90 copayment for the therapeutic phlebotomy services because the Plan is only 
holding you responsible for this amount which is less than the $250 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 therapeutic phlebotomy 
services provided on March 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on March 08, 2023. 
 
You asked the Plan to pay for wound care. You say that you say that wound care supplies are a separately 
billable expense that does not require authorization or referral. 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 wound care provided on 
March 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram monitoring provided on December 29, 
2022. 
 
You asked the Plan to pay for the electrocardiogram monitoring. You say that the service was medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the electrocardiogram 
monitoring provided on December 29, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on April 
29, 2023. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that the urgent care doctor 
had you go to the emergency room. 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 $95 
copayment for Medicare-covered emergency room visits. 
 
You have been asked to pay a $95 copayment for an emergency room visit. This item/service falls within the 
Medicare-covered emergency room 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 an emergency room visit provided on April 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient rehabilitation stay provided on March 16, 2023, 
by an OON provider.  
 
You asked the Plan to pay for case management services. You say that the service was medically necessary. 
The Plan denied your request. The Plan says an authorization was not obtained prior to the 
services being rendered. 
 
 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 case management services provided on March 16, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on February 03, 
2023. 
 
You asked the Plan to pay for a psychiatric diagnostic evaluation. 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 a psychiatric diagnostic 
evaluation provided on February 03, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on February 13, 2023. 
 
You asked the Plan to waive the copayment for an x-ray. You say that this 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 $35 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $35 copayment for an x-ray. 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 an x-ray provided on February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on March 20, 2023. 
 
You asked the Plan to pay for a specialist 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 a specialist office visit 
provided on March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for wound care on March 22, 2023, to April 
10, 2023. 
 
You asked the Plan to waive the copayments for wound care. 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 $175 
copayment for Medicare-covered services provided in an outpatient hospital. If you are having surgery in a 
hospital facility, you should check with your provider about whether you will be an inpatient or outpatient. 
Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay 
the cost-sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be 
considered an outpatient. There were three visits. 3 x $175 = $525. Therefore, results in the total cost sharing 
amount of $525. 
 
You have been asked to pay a $175 copayment for each wound care. This item/service falls 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 copayments for wound care on March 22, 2023, 
to April 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit provided by an in-network 
provider on January 5, 2023. 
 
You asked the Plan to waive the deductible for the office visit. You say that you do not understand the cost 
sharing. 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 $150 deductible which applies to the office visit. 
 
You have been asked to pay a $88.29 deductible for the office visit. The item or service you asked the Plan to 
waive the deductible for falls within the physician/practitioner services, including doctors office visits benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 
deductible which applies to physician/practitioner services, including doctors office visits. This cost sharing is 
a contractual obligation that had not been met at the time the office visit was provided on January 5, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided by an in-
network provider on January 5, 2023.