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

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on May 04, 
2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. 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 $360 
copayment for outpatient surgery/Medicare-covered observation services provided to you at an outpatient 
hospital. 
 
You have been asked to pay a $360 copayment for an outpatient surgery. This item/service falls within the outpatient surgery/Medicare-covered observation services provided to you 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. However, since 
the allowed amount is less than the standard copayment, you only owe $142.40. Therefore, we decided that the 
Plan does not have to waive the copayment for an outpatient surgery provided on May 04, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the vascular ultrasound provided on May 
23, 2023. 
 
You asked the Plan to waive the copayment for the vascular ultrasound. You say that the provider thought this 
test was necessary. 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 $120 
copayment for outpatient diagnostic radiology tests. 
 
You have been asked to pay a $120 copayment for the vascular ultrasound. This item/service falls within the 
outpatient diagnostic radiology tests 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 $103.30. Therefore, we decided that the Plan does not have to waive the copayment for the vascular 
ultrasound provided on May 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for radiologic examinations and an out-of-
network office visit provided on January 16, 2023. 
 
You asked the Plan to waive the cost share for radiologic examinations and an out-of-network 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 $300 deductible and a 20% coinsurance which applies to outpatient 
diagnostic tests and physician/practitioner services.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient diagnostic tests 
and physician/practitioner services benefit category. You are being asked to pay your $300 deductible. You are 
being asked $72.55 towards your 20% coinsurance. The total amount you are being asked to pay is $372.55 
($300 + $72.55 = $372.55). The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $300 deductible and a 20% coinsurance which applies to outpatient diagnostic tests and physician/practitioner services. This cost sharing is a contractual obligation that had not been met at the time 
radiologic examinations and an out-of-network office visit was received on January 16, 2023. Therefore, we 
decided that the Plan does not have to waive the cost share for radiologic examinations and an out-of-network 
office visit provided on January 16, 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 June 
22, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you were not enrolled in 
this Plan starting in 2023. 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 $45 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $45 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. The records show the service was provided in 2022. Therefore, 
we decided that the Plan does not have to waive the copayment for the specialist office visit provided on June 
22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93229 billed for February 28, 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 procedure code 93229 is not supported. 
 
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 93229 is external mobile cardiovascular telemetry with 
electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of 
accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events 
transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and 
patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports 
as prescribed by a physician or other qualified health care professional.  
We find that CPT code 93229 is not supported in the medical record. Specifically, the records do not document 
the technician name or credentials of the attendant of the surveillance services. 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 procedure code 93229 billed for February 28, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transportation provided on 
October 24, 2022. 
 
You asked the Plan to waive the copayment for an ambulance transportation. You say that you should not have 
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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for an ambulance transportation. 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 an 
ambulance transportation provided on October 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interrogation device evaluation(s) (remote), provided on May 
25, 2023. 
 
You asked the Plan to pay for interrogation device evaluation(s) (remote),. You say that the service was 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for interrogation device 
evaluation(s) (remote), provided on May 25, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on January 23, 2023. 
 
You asked the Plan to pay for a home visit evaluation. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit evaluation 
provided on January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on February 21, 2023, to 
May 18, 2023. 
 
You asked the Plan to pay for the acupuncture services. You say that you have submitted these claims and they 
have not been paid. 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 acupuncture services 
provided on February 21, 2023, to May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a heart catheterization procedure provided 
on February 14, 2023. 
 
You asked the Plan to waive the coinsurance for a heart catheterization procedure. You say that you were told 
that you would be charged at the in-network benefit level. 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 40% 
coinsurance for out-of-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 40% coinsurance for a heart catheterization procedure. This item/service falls within the out-of-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 total amount you owe 
is $1,395.26 ($3,488.14 allowed amount x 40% = $1,395.26). Therefore, we decided that the Plan does not 
have to waive the coinsurance for a heart catheterization procedure provided on February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an auditory evoked potentials; 
neurodiagnostic test (92653) provided on June 08, 2023. 
 
You asked the Plan to waive the copayment for an auditory evoked potentials; neurodiagnostic test (92653). 
You say that there should only be one 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 $10 
copayment for Medicare-covered hearing examination. 
 
You have been asked to pay a $10 copayment for an auditory evoked potentials; neurodiagnostic test (92653). 
This item/service falls within the Medicare-covered hearing examination 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 auditory evoked potentials; neurodiagnostic test (92653) provided 
on June 08, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on January 21, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 1, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the ambulance services provided on January 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a computed tomography (CT) scan 
performed at an outpatient hospital facility provided on June 29, 2023. 
 
You asked the Plan to reduce the copayment for a computed tomography (CT) scan performed at an outpatient 
hospital facility. You say that you were advised your copayment would be less than the amount applied and 
you would like the cost share to be reduced. 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 diagnostic tests. 
 
You have been asked to pay a $275 copayment for a computed tomography (CT) scan performed at an outpatient hospital facility. This item/service falls within the outpatient diagnostic tests 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 computed tomography (CT) scan performed at an 
outpatient hospital facility provided on June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 20, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. 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 office visit provided on April 20, 2023, by an 
OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for March 7, 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 procedure code G0483 is not supported. 
 
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 G0483 is definitive drug testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the file shows that only 21 
drug classes were tested and there is a more appropriate code for the services. 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 procedure code G0483 billed for March 7, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 07, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. 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 subsequent nursing 
facility care provided on March 07, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87502 billed for March 28, 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 procedure code 87502 is not supported. 
 
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 87502 is infectious agent detection by nucleic acid (DNA 
or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when 
performed, and multiplex amplified probe technique, first 2 types or sub-types. 
 
We find that CPT code 87502 is not supported in the medical record. Specifically, the records show that the 
number of targets performed is described by a different, more appropriate code. 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 procedure code 87502 billed for March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuing medical physics consultation provided on June 
01, 2023, to June 16, 2023. 
 
You asked the Plan to pay for continuing medical physics consultation. 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 continuing medical 
physics consultation provided on June 01, 2023, to June 16, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visits provided 
on March 20, 2023, to April 13, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visits. You say that you were never 
advised there would be a copayment for the services provided. 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 outpatient rehabilitation services.  
You have been asked to pay a $40 copayment for each physical therapy (PT) visits. This item/service falls 
within the outpatient rehabilitation 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 copayment you owe is $160 for PT services ($40 per visit x 4 
visits = $160). Therefore, we decided that the Plan does not have to waive the copayment for each physical 
therapy (PT) visits provided on March 20, 2023, to April 13, 2023.