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

 
We decided that the Plan does not have to reduce the copayment for an ultrasound provided on June 21, 2023. 
 
You asked the Plan to reduce the copayment for an ultrasound. You say that the Plan should cover more of the 
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 $110 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $110 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the 
copayment for an ultrasound provided on June 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 10, 2023. 
 
You asked the Plan to pay for lab services. You say that these 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 lab services provided on 
May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on June 23, 2023. 
 
You asked the Plan to pay for an annual wellness visit. 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 an annual wellness visit 
provided on June 23, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs (A9270) provided on June 6, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that this service should be covered. The 
Plan denied your request. The Plan says self-administered drugs are not covered under the Part B medical 
benefit when provided in the outpatient setting. 
 
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 self-administered drugs (A9270) 
provided on June 6, 2023.  
 
Benefits for the self-administered drugs 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 waive the copayment for a hearing exam provided on February 02, 
2023. 
 
You asked the Plan to waive the copayment for a hearing exam. You say that you dont agree with the 
copayment assessed for an office 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 $25 
copayment for hearing services (Medicare covered).  
You have been asked to pay a $25 copayment for a hearing exam. This item/service falls within the hearing 
services (Medicare covered) 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 hearing 
exam provided on February 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hearing exam provided on March 24, 
2023. 
 
You asked the Plan to waive the copayment for a hearing exam. You say that you dont agree with the 
copayment assessed for an office 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 $25 
copayment for hearing services (Medicare covered).  
You have been asked to pay a $25 copayment for a hearing exam. This item/service falls within the hearing 
services (Medicare covered) 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 hearing 
exam provided on March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care services provided on July 19, 2023, to July 
26, 2023. 
 
You asked the Plan to pay for chiropractic care services. You say that you requesting reconsideration because 
you feel that you were overcharged. 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 chiropractic care 
services provided on July 19, 2023, to July 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a portable gaseous oxygen system, and an 
oxygen concentrator provided on March 15, 2023, to May 15, 2023. 
 
You asked the Plan to waive the coinsurance for a portable gaseous oxygen system, and an oxygen 
concentrator. You say that you do not understand why you are being billed. 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 in-network durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for a portable gaseous oxygen system, and an oxygen 
concentrator. This item/service falls within the in-network durable medical equipment (DME) 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 $89.94 ($449.76 allowed amount x 20% = $89.94 rounded down). Therefore, we 
decided that the Plan does not have to waive the coinsurance for a portable gaseous oxygen system, and an 
oxygen concentrator provided on March 15, 2023, to May 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the dressing and/or debridement of a burn 
provided on October 28, 2022. 
 
You asked the Plan to waive the copayment for the dressing and/or debridement of a burn. You say that you do 
not agree 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 $200 
copayment for each Medicare-covered outpatient hospital service. 
 
You have been asked to pay a $200 copayment for the dressing and/or debridement of a burn. This item/service 
falls within the each Medicare-covered outpatient hospital service 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 $188.35. Therefore, we decided that the Plan does not have to waive the 
copayment for the dressing and/or debridement of a burn provided on October 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection provided on June 13, 2023. 
 
You asked the Plan to waive the copayment for an injection. You say that you say that all the doctor did was 
give you an injection in the tendon on your finger and you did not have an ultrasound nor a special treatment 
room. 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 $295 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $295 copayment for an injection. 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. However, since 
the allowed amount is less than the standard copayment, you only owe $288.03. Therefore, we decided that the 
Plan does not have to waive the copayment for an injection provided on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on May 01, 2023. 
 
You asked the Plan to pay for the nursing facility care. 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 the nursing facility care 
provided on May 01, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 19285-50-59 and 19286-LT-59 provided on 
May 24, 2023. 
 You asked the Plan to pay for procedure codes 19285-50-59 and 19286-LT-59. You say that the medical 
records support the billing of procedure codes 19285 and 19286. The Plan denied your request. The Plan says 
the medical records do not support the billing of procedure codes 19285 and 19286. 
 
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 codes 19285 and 19286 are column II codes to column I code 19301; 
however, 19285 and 19286 were billed with a modifier.  
 
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 procedure codes 19285-50-59 and 19286-LT-59. Our 
reviewer says that the medical records do not support the billing of procedure codes 19285 and 19286. Our 
reviewer found CPT codes 19285 and 19286 with a bypass modifier are not supported as separately identifiable 
procedures. The record states that they were part of the main procedure reported with 19301. According to CPT 
coding rules, clip placement is included in 19301 and should not be reported separately.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 19285-50-59 and 19286-LT-59 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 19285-50-59 and 19286-LT-59 provided on 
May 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on October 29, 2022. 
 
You asked the Plan to pay for the podiatry services. 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 the podiatry services 
provided on October 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network laboratory pathology 
provided on July 12, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-network laboratory pathology. You say that youve 
been charged too much 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 20% 
coinsurance for outpatient diagnostic tests and therapeutic services. 
 
You have been asked to pay 20% coinsurance for an out-of-network laboratory pathology. This item/service 
falls within the outpatient diagnostic tests and therapeutic 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 coinsurance for an out-of-network laboratory pathology provided on July 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0480 billed for date of service June 26, 
2023. 
 
You asked the Plan to pay for procedure code G0480. 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. 
 
We find that CPT code G0480 is not supported in the medical record. Specifically, the provided medical 
documentation does not contain a physician order indicating the tests to be performed under code G0480. Code 
G0480 cannot be verified. Based on this information, we decided that Medicare rules for coverage of procedure 
code G0480 have not been met.  
  Therefore, we decided that the Plan does not have to pay for procedure code G0480 billed for date of service 
June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for March 6, 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 G0482 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 G0482 is definitive drug testing, 15-21 drug classes. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, there is no documentation 
of definitive drug testing results for 15-21 drug classes. 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 G0482 billed for March 6, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for PT services provided on June 6, 2023, by 
an out-of-network (OON) provider. 
 
You asked the Plan to reduce the cost share for PT services. You say that the enrollee should only have a $30 
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. The 
enrollees contract with the Plan says that there is a $450 deductible which applies to outpatient rehabilitation 
services and a $55 copayment for out-of-network outpatient rehabilitation services performed in a specialists 
office, after the deductible has been met.  
 
 The item or service you asked the Plan to reduce the cost share for falls within the outpatient rehabilitation 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $450 deductible which applies to outpatient rehabilitation services. This cost sharing is a contractual 
obligation that had not been met at the time PT services was received on June 6, 2023. However, the enrollees 
deductible was met with the processing of this claim, and the correct copayment was applied according to the 
enrollees contract with the Plan. Therefore, we decided that the Plan does not have to reduce the cost share for 
PT services provided on June 6, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shingles vaccine provided on June 12, 2023. 
 
You asked the Plan to pay for a shingles vaccine. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the shingles vaccine is not a covered benefit under 
your Part B benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine. 
Therefore, we decided that the Plan does not have to pay for a shingles vaccine provided on June 12, 2023.  
 
Benefits for a shingles vaccine 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 waive the copayment for an in-network urology visit provided on 
June 26, 2023. 
 
You asked the Plan to waive the copayment for an in-network urology visit. You say that this was a follow up 
from surgery and should not have a copay. You had to wait to be seen because the provider was too far away. 
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 Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for an in-network urology 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 an in-network urology visit provided on June 26, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on June 21, 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 June 21, 2023.