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

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
February 20, 2023. 
 
You asked the Plan to waive the copayment for outpatient hospital 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 $275 
copayment for outpatient hospital services/outpatient diagnostic colonoscopies. 
 
You have been asked to pay a $275 copayment for outpatient hospital services. This item/service falls within 
the outpatient hospital services/outpatient diagnostic colonoscopies 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 outpatient hospital services provided on February 20, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on February 13, 
2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that this was not a hospital 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 $50 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $50 copayment for an ultrasound. This item/service falls within the in-network 
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. The record shows the Plan has reprocessed the 
benefits. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound provided 
on February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs an 
outpatient diagnostic test and a specialist office visit provided on March 14, 2023. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs an outpatient diagnostic test 
and a specialist office visit. You say that you disagree with the cost share. 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 $750 deductible, 20% coinsurance for Medicare Part B prescription 
drugs a $20 copayment for outpatient diagnostic test and a $35 copayment for physician/practitioner 
services/specialist.  
 The item or service you asked the Plan to waive the cost share for falls within the Medicare Part B prescription 
drugs, outpatient diagnostic test, physician/practitioner services/specialist benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible, 20% coinsurance 
for Medicare Part B prescription drugs a $20 copayment for outpatient diagnostic test a $35 copayment which 
applies to physician/practitioner services/specialist. You are being asked to pat $281.75 towards your $750 
deductible. The total allowed amount for the prescription drugs is $8.50. You are being asked to pay $1.70 
($8.50 x 20% = $1.70). The total amount you are being asked to pay is $318.45 ($281.75 +1.70 + $35 = 
$318.45). This cost sharing is a contractual obligation that had not been met at the time Medicare Part B 
prescription drugs an outpatient diagnostic test and a specialist office visit was received on March 14, 2023. 
Therefore, we decided that the Plan does not have to waive the cost share for Medicare Part B prescription 
drugs an outpatient diagnostic test and a specialist office visit provided on March 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
November 23, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you do not understand 
why you owe 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 $40 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $40 copayment for the specialist office visit. This item/service falls within the 
in-network specialist physician/practitioner 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 the specialist office visit provided on November 23, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided from October 9, 2022, 
to February 4, 2023, by an OON provider.  
 
You asked the Plan to pay for the psychotherapy services. You say that you are requesting reconsideration of 
the denied services. The Plan denied your request. The Plan says these services were 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 psychotherapy services provided on October 9, 
2022, to February 4, 2023, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99308-25 rendered on March 9, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says a review of the clinical notes do not support a significant and/or identifiable issue at this visit. 
 
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 99308 is "Subsequent nursing facility care, per day, for 
the evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and low level of medical decision making. When using total time on the date of the encounter for code 
selection, 15 minutes must be met or exceeded." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation supports that 
the evaluation and management service was provided to assess and evaluate the wound, and therefore is related 
to the wound care provided. Therefore, modifier 25 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99308-25 rendered on March 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department visit provided 
on January 13, 2023. 
 
You asked the Plan to waive the copayment for the emergency department visit. You say that you did not 
receive any 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 a $90 
copayment for each emergency room visit. 
 
 
 You have been asked to pay a $50 copayment for the emergency department visit because the Plan is only 
holding you responsible for this amount which is less than the $90 copayment. 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 the emergency 
department visit provided on January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 24, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time of service the enrollee was residing in an 
assisted living facility. 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 home visit provided 
on March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the audiology office visit provided on 
January 23, 2023. 
 
You asked the Plan to waive the copayment for the audiology office visit. You say that you did not have an 
office visit on this date. 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 specialist physician/practitioner services. 
 
You have been asked to pay a $35 copayment for the audiology office visit. This item/service falls within the 
specialist physician/practitioner 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 records show an office visit was provided on January 23, 2023. 
Therefore, we decided that the Plan does not have to waive the copayment for the audiology office visit 
provided on January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 7, 2023, by an OON 
provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 7, 2023, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 18, 2023. 
 
You asked the Plan to pay for office visit. You say that you say that you were unaware that they were out of 
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 office visit provided on 
April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 2, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 0117U for date of 
service October 20, 2022. 
 
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 claim for this molecular pathology testing did not include the 
required unique identifier. 
 
 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed 
with code 0117U for date of service October 20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone density measurement provided on February 21, 
2023. 
 
You asked the Plan to pay for the bone density measurement. You say that the services were 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 bone density 
measurement provided on February 21, 2023.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for physical therapy (PT) services provided on August 26, 2022. 
 
You asked the Plan to pay for the therapy services. You say that the services were medically necessary and 
referred by the enrollee's dentist. The Plan denied your request. The Plan says that the requested services are 
not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 pay for the therapy services. Our reviewer says that 
the services were medically necessary. Our physician reviewer found the requested physical therapy is 
generally accepted as a specific and effective therapy for TMJ dysfunction. The therapy performed required the 
skills of a physical therapist and was medically reasonable. 
 
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 therapy services have been met. Therefore, we decided that the Plan has to 
pay for physical therapy (PT) services provided on August 26, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the clinic visit and the laboratory services provided on April 
11, 2023. 
 
You asked the Plan to pay for the clinic visit and the laboratory services. You say that you are appealing the 
denial with supporting documentation. 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 clinic visit and the 
laboratory services provided on April 11, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes S9123, S9131, and S9129 billed for date of 
service February 2, 2023, to February 3, 2023. 
 
You asked the Plan to pay for procedure codes S9123, S9131, and S9129. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the billed codes are 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 codes S9123, S9131, and S9129 have a Status Indicator of I on the Physician Fee 
Schedule. This means that procedure codes S9123, S9131, and S9129 are not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of procedure codes S9123, S9131, and 
S9129 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes S9123, 
S9131, and S9129 billed for date of service February 2, 2023, to February 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telephone evaluation and management service provided on 
February 20, 2023. 
 
You asked the Plan to pay for telephone evaluation and management service. You say that this service 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 telephone evaluation and 
management service provided on February 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye examination provided on December 
16, 2022. 
 
You asked the Plan to waive the copayment for an eye examination. You say that this service should be billed 
as a routine vision exam. 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 vision care. 
 
You have been asked to pay a $35 copayment for an eye examination. This item/service falls within the vision 
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 eye examination provided on 
December 16, 2022.