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

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit (99285) 
provided on May 26, 2023, to May 27, 2023. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $90 
copayment for Emergency Care.  
 
 
  You have been asked to pay a $90 copayment for the ER visit. 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. 
Therefore, we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit 
(99285) provided on May 26, 2023, to May 27, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 13, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with 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 $245 
copayment for ambulance services. 
 
You have been asked to pay a $245 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 March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the skin lesion injection and the 
triamcinolone acetonide injection provided on June 19, 2023. 
 
You asked the Plan to waive the coinsurance for the skin lesion injection and the triamcinolone acetonide 
injection. You say that the procedure did not work. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the skin lesion injection and the triamcinolone acetonide 
injection. 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 waive the coinsurance for the skin lesion injection and the triamcinolone acetonide injection 
provided on June 19, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room (ER) visit (85025, 99284, 36415, 71046) 
provided on August 18, 2022. 
 
You asked the Plan to pay for the ER visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as the rendering provider 
is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an emergency room (ER) visit (85025, 
99284, 36415, 71046) provided on August 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80307 and G0483 provided on April 3, 
2023. 
 
You asked the Plan to pay for procedure codes 80307 and G0483. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  
Medicare rules say while a physician order is not required to be signed, the physician must clearly document, in 
the medical record, the intent that the test be performed. 
 
We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, medical 
records submitted do not include an order that specifically list what test(s) are to be performed in the custom 
panel. Based on this information, we decided that Medicare rules for coverage of procedure codes 80307 and 
G0483 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 80307 
and G0483 provided on April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network chiropractic visit 
provided on December 07, 2022. 
 
You asked the Plan to waive the coinsurance for an out-of-network chiropractic visit. You say that you feel you 
are not being reimbursed correctly for these 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 50% 
coinsurance for chiropractic services. 
 
You have been asked to pay 50% coinsurance for an out-of-network chiropractic visit. This item/service falls 
within the chiropractic 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. The total you owe is $19.16 ($38.32 allowed amount x 50% = $19.16) 
Therefore, we decided that the Plan does not have to waive the coinsurance for an out-of-network chiropractic 
visit provided on December 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 19, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the outpatient surgery services provided by 
an in-network provider on May 10, 2023. 
 
You asked the Plan to waive the deductible for the surgery services. You say that no one told you how much 
the procedure would cost. 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 $1000 deductible which applies to outpatient surgery services. 
 
 
 
 
 
 
 You have been asked to pay a $738.58 deductible for the surgery services. The items or services you asked the 
Plan to waive the deductible for fall within the outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers benefit category. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $1000 deductible which applies to outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a 
contractual obligation that had not been met at the time the surgery services were provided on May 10, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for the outpatient surgery services 
provided by an in-network provider on May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular reeducation provided on May 4, 2023, by 
an OON provider.  
 
You asked the Plan to pay for the neuromuscular reeducation. You say that you are appealing the denial with 
supporting documentation. 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 the neuromuscular reeducation provided on May 
4, 2023, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility care on March 01, 
2023, to March 24, 2023.  
 
You asked the Plan to waive the copayment for skilled nursing facility care. You say that you believe that the 
copayment is wrong because you should be charged the copayment for inpatient hospital stay $395 per day. 
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 each day for Medicare-covered days 1 to 20. A $196 copayment each day for Medicare-covered 
days 21 to 55 for skilled nursing facility care. There was a stay from February 15, 2023, to February 28, 2023, 
which were days 1-14. Days 15-37 are from March 01, 2023, to March 24, 2023. There were seventeen days in 
this period. 17 x $196 = $3,332. Therefore, results in the total cost sharing amount of $3,332. 
 
You have been asked to pay a $196 copayment each day for skilled nursing facility care. 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 care on March 01, 2023, to March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening mammogram and the screening digital breast 
tomosynthesis provided on May 17, 2023, by an OON provider.  
 
You asked the Plan to pay for the screening services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits 
for these services. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has a POS option to use either network providers or out-of-network providers for certain 
covered services. The Plan contract also says that out-of-network breast cancer screening services are not 
covered. 
 
The requested provider in this case is not a network provider with the Plan. 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 screening mammogram and the screening 
digital breast tomosynthesis provided on May 17, 2023, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on April 21, 2023. 
 
You asked the Plan to pay for the laboratory service. 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 laboratory service 
provided on April 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you have submitted medical records to support 
the request for reconsideration of the authorization denial. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychological/neuropsychological testing services provided 
on May 22, 2023. 
 
You asked the Plan to pay for psychological/neuropsychological testing services. You say that this is supported 
in the 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 
psychological/neuropsychological testing services provided on May 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polycarbonate lenses, anti-reflective coating, and ultraviolet 
(U-V) lenses provided on June 13, 2023. 
 
You asked the Plan to pay for polycarbonate lenses, anti-reflective coating, and ultraviolet (U-V) lenses 
provided. You say that you have been going to this provider since 2018 and never had a problem with the 
charges. The Plan denied your request. The Plan says the additional lens enhancements and coatings are not a 
covered benefit under you Plan benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these lenses when the lenses are single vision lenses, lined bifocal lenses, and lined 
trifocal lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers single vision lenses, lined 
bifocal lenses, and lined trifocal lenses. Polycarbonate lenses, anti-reflective coating, and ultraviolet (U-V) 
lenses are not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of 
polycarbonate lenses, anti-reflective coating, and ultraviolet (U-V) lenses provided have not been met. 
Therefore, we decided that the Plan does not have to pay for polycarbonate lenses, anti-reflective coating, and 
ultraviolet (U-V) lenses provided on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 provided on June 5, 2023. 
 
You asked the Plan to pay for procedure code 99152. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the record does not support the billing of 
procedure code 99152. 
 
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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 We find that CPT code 99152 is not supported in the medical record. Specifically, according to CPT and CMS 
guidelines, there is a more appropriate code for moderate sedation provided during an endoscopic procedure, 
G0500. This should be reported instead of 99152. Based on this information, we decided that Medicare rules 
for coverage of procedure code 99152 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 99152 provided on June 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for digital, binaural hearing aids (V5261) provided on 
April 5, 2023. 
 
You asked the Plan to reimburse for digital, binaural hearing aids (V5261). You say that you are confused 
because you received two hearing aids, but you only received a $500 check and not the full amount for your 
out-of-pocket. The Plan denied your request. The Plan says the hearing aids purchased on April 5, 2023, 
exceeded the maximum allowed for the hearing aid reimbursement. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan rules say 
they cover up to a $500 allowance every three years towards the cost of the hearing aids. 
 
 
  We looked at the file, and the Plan's rules. The Plan rules say they cover up to a $500 allowance every three 
years towards the cost of the hearing aids. The Plan rules also say you are responsible for all charges over 
$500. The record shows this benefit was exhausted with this date of service. Based on this information, we 
decided that the Plan's rules for coverage of digital, binaural hearing aids (V5261) have not been met. 
Therefore, we decided that the Plan does not have to reimburse for digital, binaural hearing aids (V5261) 
provided on April 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a transthoracic echocardiogram (TTE) 
provided on May 23, 2023. 
 
You asked the Plan to reduce the copayment for a transthoracic echocardiogram (TTE). You say that you think 
that the copayment should be lower. 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 in-network advanced imaging services performed at an outpatient hospital. 
 
You have been asked to pay a $250 copayment for a transthoracic echocardiogram (TTE). This item/service 
falls within the in-network advanced imaging services performed at 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 reduce the copayment for a transthoracic echocardiogram (TTE) provided on May 23, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for each acupuncture service provided on 
October 25, 2022, to December 05, 2022. 
 
You asked the Plan to reduce the coinsurance for each acupuncture service. You say that the coinsurance is too 
high. 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 10% 
coinsurance for acupuncture for chronic low back pain. 
 
You have been asked to pay 10% coinsurance for each acupuncture service. This item/service falls within the 
acupuncture for chronic low back pain 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 amount you owe for each visit is $3.88 ($38.78 allowed amount x 10% = 
$3.88). The total amount you owe is $50.44 ($3.88 coinsurance x 13 visits = $50.44). Therefore, we decided 
that the Plan does not have to reduce the coinsurance for each acupuncture service provided on October 25, 
2022, to December 05, 2022.