Persius/hicric huggingface dataset:
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 
November 18, 2022. 
 
You asked the Plan to waive the copayment for a new patient office visit. You say that you do not think that 
there should be a copayment for 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 $5 
copayment for in-network provider and professional services provided in a primary care provider (PCP) office. 
 
You have been asked to pay a $5 copayment for a new patient office visit. This item/service falls within the in-network provider and professional services provided in a primary care provider (PCP) office 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 November 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 10, 2023. 
 
You asked the Plan to pay for lab services. You say that the enrollee wishes to continue seeking services with 
this provider. 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 lab services provided on 
January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 08, 2023, by an out-of-
network (OON) provider.  
 
 You asked the Plan to pay for an office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of the plans network) will not be covered.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on February 08, 2023, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital observation services provided 
on January 20, 2023, to January 21, 2023. 
 
You asked the Plan to waive the copayment for the hospital observation services. You say that you had no 
choice but to go to a different 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 $110 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $110 copayment for the hospital observation services. This item/service falls 
within the outpatient hospital observation 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 hospital observation services provided on January 20, 2023, to January 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote patient monitoring services provided on January 
16, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the remote patient monitoring services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says enrollees must receive their care from a 
network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
items/services 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 remote patient monitoring services provided 
on January 16, 2023, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance provided on November 17, 
2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you say you have limited income. 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 ambulance services. 
 
You have been asked to pay a $150 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 
November 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0152 billed for home health services 
rendered from January 25, 2023, to February 23, 2023. 
 
You asked the Plan to pay for procedure code G0152. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have 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 G0152 is: Services performed by a qualified occupational 
therapist in the home health or hospice setting, each 15 minutes. 
 
We find that CPT code G0152 is not supported. Specifically, the claim at issue has been reported with revenue 
code 0551 for skilled nursing services. Code G0152 does not indicate skilled-nursing services but rather occupational-therapist services. Based on this information, we decided that Medicare rules for coverage of 
procedure code G0152 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0152 billed for home health services rendered from January 25, 2023, to February 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the life vest provided on March 11, 2023, 
to March 20, 2023. 
 
You asked the Plan to reduce the coinsurance for the life vest. You say that you had not worn the vest for the 
whole month. 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 durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the life vest. This item/service falls within the durable 
medical equipment 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. The total you owe is $616.19 ($3,080.95 allowed amount x 20% = 
$616.19). Therefore, we decided that the Plan does not have to reduce the coinsurance for the life vest provided 
on March 11, 2023, to March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on May 03, 2023. 
 
You asked the Plan to waive the copayment for office visit. You say that you say that you paid $35 the last 6 
months. 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 $75 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $75 copayment for office visit. This item/service falls within the 
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. Therefore, we decided that the Plan does not have 
to waive the copayment for office visit provided on May 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on November 09, 2022. 
 
You asked the Plan to pay for wound care. You say that the assisted living facility is responsible to obtain prior 
authorization for all patients. 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 
November 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93042 and 99291 billed for date of service 
July 24, 2022.  
 
You asked the Plan to pay for procedure codes 93042 and 99291. The Plan denied your request. The Plan says 
the billed codes are not payable in this case. 
 
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 93042 is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. 
 
In this case, the CPT Code Manual definition of code 99291 is Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not show that 
30-74 minutes of critical care services were provided on the date of service in question. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99291 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 93042 and 99291 billed for date 
of service July 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections on February 01, 2023, to 
February 10, 2023.  
 
You asked the Plan to waive the coinsurance for injections. 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 Medicare Part B drugs when administration or observation by medical personnel is required, 
and the drugs are administered to you by a network provider. Covered drugs include drugs that usually aren't 
self-administered by the patient and are injected or infused while you are getting physician, hospital outpatient, 
or ambulatory surgical center services. The provider billed in the amount of $3,423.75 and the allowed amount 
is $453.18 for the services. $453.18 x 20% = $90.64. There were ten visits. 10 x $90.64 = $906.40. Therefore, 
results in the total cost sharing amount of $906.40. 
 
You have been asked to pay a 20% coinsurance for injections. This item/service falls within the Medicare Part 
B prescription drug 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 injections on 
February 01, 2023, to February 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for melanoma testing provided on September 29, 2022. 
 
You asked the Plan to pay for melanoma testing. You say that this testing 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 melanoma testing 
provided on September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the genvisc injections and the specialist 
office visits provided from January 9, 2023, to February 10, 2023. 
 
You asked the Plan to waive the cost share for the injections and the specialist office visits. You say that the 
provider was rude. 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 out-of-network Medicare Part B covered drugs. Your contract with the Plan also clearly says 
that you must pay a $65 copayment for out-of-network provider and professional services. You have been asked to pay $40.45, which is 20% coinsurance of the allowed amount for the for each injection 
provided on January 9, 2023, January 13, 2023, January 16, 2023, January 20, 2023, January 23, 2023, January 
27, 2023, January 30, 2023, February 3, 2023, February 6, 2023, and February 10, 2023 ($202.25 coinsurance x 
20% = $40.45). These items/services fall 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.  
 
You have been asked to pay a $65 copayment for each specialist office visit provided on January 9, 2023, 
January 13, 2023, January 16, 2023, January 20, 2023, January 23, 2023, January 27, 2023, January 30, 2023, 
February 3, 2023, February 6, 2023, and February 10, 2023. These items/services fall within the 
physician/practitioner services, including doctor's office 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 cost share for the genvisc injections and the specialist office visits provided from January 9, 2023, 
to February 10, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 2, 2023. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says this was a 
routine annual exam request and not an emergency. Services may therefore be performed by numerous network 
providers. 
 
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 physician's services provided on March 2, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided January 11, 2023 to January 30, 
2023. 
 
You asked the Plan to pay for the hospital services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says a correct claim is required. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the billed services are not supported in the medical record. Specifically, the claim was submitted 
without the required 84 condition code. Based on this information, we decided that Medicare rules for coverage 
of the hospital services have not been met. Therefore, we decided that the Plan does not have to pay for 
hospital services provided January 11, 2023 to January 30, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on April 19, 2023. 
 
You asked the Plan to pay for the psychotherapy. The Plan denied your request. The Plan says counselors are 
not covered by Medicare or your Health Plan.  
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for psychotherapy provided on April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on January 11, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
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 home visit provided on 
January 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for lab services on July 11, 2022, to 
September 19, 2022. 
 
You asked the Plan to waive the copayments for lab services. You say that you should not be charged a 
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 $5 
copayment for Medicare-covered outpatient lab services at a free-standing radiology clinic. Covered services 
include but are not limited to laboratory tests. There were two visits. 2 x $5 = $10. Therefore, results in the total 
cost sharing amount of $10.  
 You have been asked to pay a $5 copayment for each lab service. 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 
copayments for lab services on July 11, 2022, to September 19, 2022.