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

 
We decided that the Plan does not have to waive the copayment for an in-network eye appointment provided on 
May 12, 2023. 
 
You asked the Plan to waive the copayment for an in-network eye appointment. You say that you went in for a 
routine eye exam, you shouldnt 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 $20 
copayment for vision services. 
 
You have been asked to pay a $20 copayment for an in-network eye appointment. This item/service falls within 
the vision 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 in-network eye 
appointment provided on May 12, 2023.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient physical therapy (PT) services provided from February 3, 
2023, through February 27, 2023, billed with codes 97110, 97112, 97116, and 97530, all reported with 
modifier -GP.  
 
You asked the Plan to pay for the PT services as billed with modifier -GP. You say that the records support the 
services as billed. The Plan denied your request. The Plan says that the GP modifier is not supported for these 
services. 
 
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 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 PT services as billed with modifier -GP. Our reviewer 
says that the codes at issue and the reported modifier are supported by the records submitted. Our reviewer 
found the provider reported the procedure codes with appended modifier GP, meaning services delivered under 
an outpatient physical therapy plan of care, which requires three components: diagnosis; long term treatment 
goals and type, amount, duration, and frequency of therapy services.  
 
The Plan of Care for dates of service February 13, 2023 - February 24, 2023, includes a diagnosis; four types of 
long-term goals; duration and frequency, noted as twice per week for 4 weeks. The record includes 2 plan of 
care notes, one for dates January 17, 2023, through February 15, 2023, and a recertification plan of care for 
dates February 13, 2023, through March 14, 2023. These documents support the use of the modifier for the 
services rendered. 
 
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 PT services as billed with modifier -GP have not been met. Therefore, we 
decided that the Plan has to pay for the outpatient physical therapy (PT) services provided from February 3, 
2023, through February 27, 2023, billed with codes 97110, 97112, 97116, and 97530, all reported with 
modifier -GP.   
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on June 02, 2023. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration stating please review 
the attached for proper processing of the claim and payment and the referral is attached. 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 testing provided on 
June 02, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network ambulance ride provided on 
January 27, 2023. 
 
You asked the Plan to waive the copayment for an in-network ambulance ride. You say that this was an 
emergency, you would like this to be waived or lowered. It is waived if you are admitted to the hospital. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for ambulance services. 
 
You have been asked to pay a $325 copayment for an in-network ambulance ride. 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 in-
network ambulance ride provided on January 27, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on May 22, 2023, to May 29, 
2023. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
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 nursing facility care 
provided on May 22, 2023, to May 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on June 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that this would not be 
covered as you were in pain. 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 May 9, 2023. Therefore, 
we decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on June 19, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound provided on April 11, 2023. 
 
You asked the Plan to pay for an ultrasound. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an ultrasound provided 
on April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, an intravenous infusion, an iron sucrose 
injection, and a heparin sodium injection provided on May 31, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for an office visit, an intravenous infusion, an iron sucrose injection, and a heparin 
sodium injection. You say that the claim should be reprocessed. The Plan denied your request. The Plan says 
that the services are available in network.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit, an intravenous infusion, an iron 
sucrose injection, and a heparin sodium injection provided on May 31, 2023, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an in-network pre-surgical visit provided 
on July 6, 2023. 
 
You asked the Plan to waive the copayments for an in-network pre-surgical visit . You say that this was part of 
a pre-operative visit, and everything should be under that. You should not need to pay any copayments. 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 each basic imaging service (e.g., general x-rays or ultrasound), and a $35 copayment for each 
in-person specialist office visit.  
 You have been asked to pay a $60 total copayment for an in-network pre-surgical visit. This item/service falls 
within the for each basic imaging service (e.g., general x-rays or ultrasound) and each in-person specialist 
office visit benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayments for an in-network pre-surgical 
visit provided on July 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telemedicine visit provided on April 06, 2023. 
 
You asked the Plan to pay for a telemedicine visit. You say that the enrollee was in a nursing home at the time 
services were rendered. 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 telemedicine visit 
provided on April 06, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you are not able to walk steady with 
confidence. You also say that your legs are not strong enough.  The Plan denied your request. The Plan says 
there is no documentation a home assessment has been completed. 
 
The Plan must follow Medicare rules. Medicare rules say that prior to or at the time of delivery of a power 
operated vehicle (POV) or power wheelchair (PWC), the supplier or practitioner must perform an on-site 
evaluation of the beneficiarys home to verify that the beneficiary can adequately maneuver the device that is 
provided. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power scooter have not been met. Therefore, we decided that the Plan does not have to pre-
approve a power scooter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network colonoscopy with biopsy 
provided on July 05, 2023. 
 
You asked the Plan to waive the copayment for an in-network colonoscopy with biopsy. You say that you were 
not advised of this loophole for a copayment, nor was the information made clear in either the literature or the 
office. This was supposed to be a simple screening. 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 Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $250 copayment for an in-network colonoscopy with biopsy. 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 an in-network colonoscopy 
with biopsy provided on July 05, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
June 03, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you should not be 
responsible for 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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for an emergency room (ER) visit. 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 an 
emergency room (ER) visit provided on June 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on May 16, 2023. 
 
You asked the Plan to pay for a facility visit. You say that this was medically necessary and the facility is 
responsible for getting prior authorization. The Plan denied your request. The Plan says that unauthorized, out-
of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a facility visit provided 
on May 16, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient therapy (97110, 97530) provided on April 11, 
2023, by an OON provider.  
 
You asked the Plan to pay for the outpatient therapy (97110, 97530). You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says the services were provided out-of-network and 
were not approved in advanced. 
 
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 outpatient therapy (97110, 97530) provided on 
April 11, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dermatology visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a dermatology visit. You say that you are dissatisfied with the in-network 
provider. They did not treat your issues and gave you issues. The Plan denied your request. The Plan says there 
are other providers available who are in-network, who are within the Medicare allowable distance from your 
residence. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a dermatology visit to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on June 08, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
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 nursing facility care 
provided on June 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on May 16, 2023. 
 
You asked the Plan to pay for a home visit. You say that the enrollee is home bound. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
May 16, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on May 12, 2023. 
 
You asked the Plan to pay for home visit. You say that you are appealing the claim payment denial. 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 home visit provided on 
May 12, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
June 01, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you should not be 
charged a second ER copayment because the facility should not have allowed you to leave without a computed 
tomography (CT) scan. 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 emergency care. 
 
You have been asked to pay a $90 copayment for an emergency room (ER) visit. 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 an emergency room 
(ER) visit provided on June 01, 2023.