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

 
We decided that the Plan does not have to waive the copayment for outpatient coronary angiography provided 
on January 23, 2023. 
 
You asked the Plan to waive the copayment for outpatient coronary angiography. You say that you did not 
expect the copay to be that much. 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 outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $325 copayment for outpatient coronary angiography. This item/service falls 
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 coronary 
angiography provided on January 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a mandibular complete denture and unspecified 
removable prosthodontic procedure (D5120, D5899) provided on January 17, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your $2,000 dental benefit maximum 
allowance for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 17, 2023. 
Therefore, we decided that the Plan does not have to pay more for a mandibular complete denture and 
unspecified removable prosthodontic procedure (D5120, D5899) provided on January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management provided on October 20, 
2022.  
You asked the Plan to pay for hospital discharge day management. The Plan denied your request. The Plan says 
Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital discharge day management provided on October 20, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 8, 2022, to 
September 26, 2022. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 8, 2022. The NOA was not received by the Plan until September 
16, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from September 8, 2022, to September 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the diagnostic colonoscopy provided on 
July 6, 2022. 
 
You asked the Plan to waive the deductible for the diagnostic colonoscopy. You say that you would like the 
colonoscopy to be reprocessed as a preventative procedure and not a diagnostic procedure. 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 which applies to outpatient surgery. Your contract 
with the Plan also says that you must pay a $125 copayment after meeting the deductible for outpatient surgery. 
 
The medical records show that a diagnostic colonoscopy was provided. You have been asked to pay $726.64 
towards the deductible. The item or service you asked the Plan to waive the deductible for falls within the outpatient surgery benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $750 deductible which applies to outpatient surgery. This cost sharing is a contractual obligation 
that had not been met at the time the diagnostic colonoscopy was received on July 6, 2022. Therefore, we 
decided that the Plan does not have to waive the deductible for the diagnostic colonoscopy provided on July 6, 
2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the mental health services provided on 
May 6, 2021, and July 24, 2021. 
 
You asked the Plan to waive the copayments for the mental health services. You say that there should be a $0 
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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $40 copayment for each out-of-network Medicare-covered individual therapy visit.  
 
 
 
 The enrollee has been asked to pay a $40 copayment for each mental health visit provided on May 6, 2021, and 
July 24, 2021. You have been asked to pay a total of $80 ($40 copayment x 2 visits = $80). These 
items/services fall within the outpatient mental health care benefit category. This means that the enrollee has 
been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayments for the mental health services provided on May 6, 2021, and July 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard provided on January 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that your provider assured you that you had enough 
of a balance to cover the cost of the bite guard. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 4, 2023. 
Therefore, we decided that the Plan does not have to pay for the occlusal guard provided on January 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient office visit, and the x-rays of the spine 
provided by an out-of-network (OON) provider on December 20, 2022, and the chiropractic treatments 
provided by an out-of-network (OON) provider on December 21, 2022. 
 
You asked the Plan to pay for the office visit, the x-rays, and the chiropractic treatments. You say that you do 
not agree with the denial of these services. The Plan denied your request. The Plan says you generally must 
receive your care from a network provider. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the new patient office visit, and the x-rays of the spine provided by an out-of-network (OON) 
provider on December 20, 2022, and the chiropractic treatments provided by an out-of-network (OON) 
provider on December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 30, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
Please reconsider payment. 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 office visit provided 
on January 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stays provided from 
September 2, 2022, to November 22, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stays. You say that you thought this 
copayment applies to the whole year. 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 per day for days 1-7 of each inpatient hospital stay. Your contract with the Plan also clearly says that you then pay a $0 copayment per day for days 8-90 of the same inpatient stay. 
 
You have been asked to pay a $150 copayment per day for days 1-7 of the inpatient hospital stay provided from 
September 2, 2022, to September 9, 2022. You have also been asked to pay a $150 copayment per day for days 
1-7 of the inpatient hospital stay provided from November 15, 2022, to November 22, 2022. You have not been 
charged after day seven or for the day you were discharged. These items/services fall within the inpatient 
hospital care benefit category.  
 
You have been asked to pay $1,050 for each inpatient hospital stay ($150 copayment per day x 7 days = 
$1,050). You have been asked to pay a total of $2,100 ($1,050 copayment + $1,050 copayment = $2,100). 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 inpatient hospital stays provided from September 2, 
2022, to November 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87631 provided on June 16, 2022. 
 
You asked the Plan to pay for procedure code 87631. You say that you would like the Plan to reconsider their 
denial of payment. 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 procedure code 87631 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87631 
provided on June 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from July 31, 2022, through 
August 1, 2022, at a foreign hospital. 
 
You asked the Plan to pay for the foreign medical services. You say that you are appealing for reconsideration 
of the denied charges. The Plan denied your request. The Plan says payment will be reconsidered whenever 
proof of payment is provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Review of the file shows that you have not paid for any services; 
therefore, you cannot be reimbursed for services you have not paid for. Emergency or an urgent need for care 
outside of the U.S. and its territories, you will be responsible to pay for those services upfront and request 
appropriate reimbursement from us. The Plan will reimburse you, for covered out-of-network emergency and 
urgent care services outside of the U.S. and its territories, at rates no greater than the rates at which Original 
Medicare would pay for such services had the services been performed in the United States in the locality 
where you reside. Payment will be reconsidered whenever proof of payment is provided. Therefore, we decided 
that the Plan does not have to pay for the medical services provided from July 31, 2022, through August 1, 
2022, at a foreign hospital.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital level of care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee's shoulder needs to 
be replaced. The Plan denied your request. The Plan says the enrollee does not meet criteria for inpatient level 
of care and this surgery could be performed on an ambulatory/observation basis. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient level of care are met in this case. Our 
physician reviewer found an admitting physician would not reasonably expect that the enrollee's necessary 
hospital care will span at least 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital level of care.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 96372. We decided that the Plan does not have to pay 
for procedure code 99213-25.  
 
You asked the Plan to pay for procedure codes 99213-25 and 96372 billed for date of service August 22, 2022.. 
You say that supporting documentation was provided. The Plan says that the documentation does not 
substantiate the services. 
 
We decided that the Plan has to pay for procedure code 96372.  
 
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 96372 is therapeutic, prophylactic, or diagnostic injection 
(specify substance or drug); subcutaneous or intramuscular. We find that CPT code 96372 is supported in the 
medical record. Specifically, the records show that the service was provided intramuscularly (IM). Based on 
this information, we decided that Medicare rules for coverage have been met. Therefore, we decided that the 
Plan has to pay for procedure code 96372 billed for date of service August 22, 2022.  
 
We also decided that the Plan does not have to pay for procedure code 99213-25. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that code 99213, billed with the -25 modifier, was not a significant 
and separately identifiable evaluation and management service. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99213-25. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drug provided on September 16, 2021. 
 
You asked the Plan to pay for the self-administered drug. You say that prior to the surgery you contacted the 
Plan and were advised your copay would be $270.00. You also say that the provider you went to is an in-
network provider. 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 pay for the self-administered drug 
provided on September 16, 2021.  
 
Benefits for the self-administered drug 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says the requested facet joint injections do not meet the 
Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 facet joint injections. Our reviewer says 
that the requested facet joint injections are not considered medically necessary in this case. Our physician 
reviewer found that a plain film of the lumbar spine does not show spondylosis and shows pathology at  
L2-L3. The request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 81405 for October 
13, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the 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 the laboratory services billed with code 81405 for October 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), and 
electronic connection between wheelchair controller and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve an expandable controller, harness, and electronic connection. You say that 
the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met. 
 
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 an expandable controller, harness, and 
electronic connection. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found you have adequate upper body strength to manage standard power drive controls. The requested items 
are not necessary to meet your needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, harness, and electronic connection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness 
(E2313), and electronic connection between wheelchair controller and two or more power seating system 
motors (E2311).