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

 
We decided that the Plan does not have to pay for the office visit and testing provided on August 11, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for these services. You say that you did not have time to obtain authorization. The 
Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior 
authorization. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 office visit and testing provided on August 11, 2023, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (ECG) provided on September 14, 
2023. 
 
You asked the Plan to pay for an electrocardiogram (ECG). You say that you made every effort possible to stay 
in-network. 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 electrocardiogram 
(ECG) provided on September 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on September 01, 
2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you went to the provider for an 
annual physical. 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 
copayment for in-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $20 copayment for an office visit. This item/service falls within the in-network 
physician/practitioner services, including doctors 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. The records show issues outside the scope of the 
annual wellness visits were discussed. Therefore, we decided that the Plan does not have to waive the 
copayment for an office visit provided on September 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99211) electrical stimulation 
(unattended) (G0283) application of modality to one or more areas; traction, mechanical (97012) and 
application of a modality to one or more areas; hot or cold packs (97010) provided May 2, 2023, to July 19, 
2023. 
 
You asked the Plan to pay for the chiropractic services. You say that you were instructed by your back doctor 
to seek physical therapy. The providers on the Plan's provider's list were not taking new patients so you went to 
this provider who has helped you in the past. The Plan denied your request. The Plan says these services are not 
covered when rendered by a chiropractor. 
 
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 the outpatient office visit (99211) electrical stimulation (unattended) (G0283) 
application of modality to one or more areas; traction, mechanical (97012) and application of a modality to one 
or more areas; hot or cold packs (97010) provided May 2, 2023, to July 19, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99213 provided on May 12, 2022. 
 
You asked the Plan to pay for procedure code 99213. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the provider is not in-network. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for procedure code 99213 by a contract provider. The file does not show that the Plan 
provided notice that procedure code 99213 would not be covered. Under Medicare rules, this means procedure 
code 99213 is considered approved by the Plan. Therefore, we decided that the Plan has to pay for procedure 
code 99213 provided on May 12, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on August 22, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the home visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services rendered are not covered when provided by an OON 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 home visit provided on August 22, 2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93990 billed for date of service July 25, 
2023. 
 You asked the Plan to pay for procedure code 93990. You say that the service was billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 93990 is bundled into payment for code 
93923. 
 
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 93990 
is a column II code to column I code 93923. 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 93990 billed for date of service July 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the lab services provided on August 22, 
2023. 
 
You asked the Plan to waive the coinsurance for the lab services. You say that the provider was previously in-
network. 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 45% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 45% coinsurance for the lab services. 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. However, the total amount you owe is $82.97, which is less than 
45% coinsurance of the allowed amount. Therefore, we decided that the Plan does not have to waive the 
coinsurance for the lab services provided on August 22, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service September 
24, 2023, to October 7, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service September 24, 2023, to October 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 17, 2023, to 
February 11, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the plan of care is not signed. 
 
The Plan must follow Medicare rules. Medicare rules say that the plan of care for home health services must be 
signed by the physician. 
 
We looked at the file and Medicare rules. The file shows that the plan of care was not signed and dated by the 
physician. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
January 17, 2023, to February 11, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on September 18, 
2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that nowhere do you see a $150 
copayment on your wallet card. 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 $150 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $150 copayment for an ultrasound. 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 ultrasound provided on September 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided on 
August 09, 2023, to August 11, 2023. 
 
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you were not admitted 
to the hospital. 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 $325 
copayment for inpatient hospital care. 
 
You have been asked to pay a $325 copayment for the 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. You have been asked to pay a total of $650 for the inpatient hospital stay ($325 copayment 
x 2 days = $325). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to reduce the copayment for the inpatient hospital stay provided on August 09, 2023, to 
August 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tradjenta (J8499). 
 
You asked the Plan to pre-approve the medication. You say that you believe that Tradjenta is the most 
appropriate treatment for this patient. The Plan denied your request. The Plan says the medication is not 
covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tradjenta (J8499).  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on 
September 11, 2023. 
 
You asked the Plan to waive the coinsurance for the denosumab injection. You say that you were told that the 
injection would 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the denosumab 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. The total amount you owe is $287.82, which is less than 20% coinsurance. 
Therefore, we decided that the Plan does not have to waive the coinsurance for the denosumab injection 
provided on September 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable and ready 
for the next level of care. The Plan denied your request. The Plan says the LTACH services requested do not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient is still somewhat unstable and requires additional acute care services that 
can safely be provided at the current facility until they are more stable for transfer. Transfer to the LTACH is 
not medically necessary as it would not be clinically advantageous and completion of treatment at the current 
facility is recommended.   
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) 
provided on September 14, 2023. 
 
You asked the Plan to waive the copayment for the magnetic resonance imaging (MRI). You say that you feel 
there should be no charge for the MRI you received. 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 $200 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $200 copayment for the magnetic resonance imaging (MRI). 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. However, since the allowed amount is 
less than the standard copayment, you only owe $195.98. Therefore, we decided that the Plan does not have to 
waive the copayment for the magnetic resonance imaging (MRI) provided on September 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided by a certified surgical 
assistant (CSA) on September 8, 2023. 
 
You asked the Plan to pay for the CSA services. You say that you have provided medical records to support the 
services billed. The Plan denied your request. The Plan says the provider of service is ineligible to provide 
surgical assistant services for Medicare. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided 
by a certified surgical assistant (CSA) on September 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair (E0240) provided February 22, 2023. 
 
You asked the Plan to pay for a shower chair. You say that this is a necessary piece of equipment due to your 
condition. The ordering physician felt it was necessary as you are unable to walk or stand. 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 (E0240) provided February 
22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 22, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not payable as billed. 
 
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 laboratory services provided on September 22, 
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 the evaluation and management (E&M) services described 
by code 99291-24 performed on date of service September 26, 2023. 
 
You asked the Plan to pay for 99291-24. You say that 99291-24 should be paid as billed because it is supported 
in the documentation. The Plan denied your request. The Plan says 99291-24 is denied because it was billed 
without an appropriate modifier on the same day as minor surgical procedure 31624.  
The Plan must follow Medicare rules. Medicare rules say that a significant and separately identifiable E&M 
service unrelated to the decision to perform a minor surgical procedure is separately reportable with modifier -
25. 
 
We looked at the file and Medicare rules. In this case we confirmed that 99291 with modifier -24 appended 
was billed on the same day as procedure code 31624. We confirmed that procedure code 31624 has a global 
surgery indicator of 000, which means it has a global surgery period of 0 days and is considered a minor 
surgical procedure. Per Medicare rules, a significant and separately identifiable E&M service unrelated to the 
decision to perform a minor surgical procedure such as 31624 is separately reportable on the same date with 
modifier -25. Based on this information, we decided that Medicare rules for coverage of 99291-24 have not 
been met. Therefore, we decided that the Plan does not have to pay for the evaluation and management (E&M) 
services described by code 99291-24 performed on date of service September 26, 2023.