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

 
We decided that the Plan does not have to pay for a podiatry visit provided on November 03, 2022. 
 
You asked the Plan to pay for a podiatry visit. 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 a podiatry visit provided 
on November 03, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary for the enrollee.  
The Plan denied your request. The Plan says the enrollee's condition and records do not meet all the 
requirements; care can be provided in the current inpatient hospital. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 for date of service March 20, 2023. 
 
You asked the Plan to pay for procedure code 99214. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. 
 
We find that CPT code 99214 is not payable as billed. Specifically, this code was billed with diagnosis codes 
M54.12 (Radiculopathy, cervical region) and M50.13 (Cervical disc disorder with radiculopathy, cervicothoracic region). Due to an 
Excludes1 note, these two diagnosis codes should not be billed together. The claim is not payable as billed. 
Based on this information, we decided that Medicare rules for coverage of procedure code 99214 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99214 for date of service 
March 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for inpatient hospital stay on October 10, 2022, 
to October 15, 2022.  
 
You asked the Plan to waive the cost share for inpatient hospital stay. You say that you want to appeal the 
amount being charged. 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% 
coinsurance for each Medicare-covered hospital stay each time you are admitted. Includes inpatient acute, 
inpatient rehabilitation, long-term care hospitals, and other types of inpatient hospital services. Inpatient 
hospital care starts the day you are formally admitted to the hospital with a doctors order. The day before you 
are discharged is your last inpatient day. You have met $281.41 of your $600 annual deductible. There is a 
$318.59 deductible. You are responsible for a 20% coinsurance for each Medicare-covered hospital stay with a 
coinsurance amount of $886.30. $318.59 + $886.30 = $1,204.89. Therefore, results in the total cost sharing 
amount of $1,204.89. 
 
You have been asked to pay a $318.59 deductible and a 20% coinsurance for inpatient hospital stay. This 
item/service falls within the inpatient hospital 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 
cost share for inpatient hospital stay on October 10, 2022, to October 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet all the requirements; care can 
be provided in the current inpatient hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 29, 2023. 
 
You asked the Plan to pay for an office visit. 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 office visit provided 
on March 29, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided on March 01, 2023. 
 
You asked the Plan to pay for emergency room services. You say that you believe the services are 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 emergency room 
services provided on March 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmological services provided on 
November 23, 2022. 
 
You asked the Plan to waive the copayment for ophthalmological services. You say that you want to appeal the 
amount being charged. 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 $30 
copayment for vision care. 
 
You have been asked to pay a $30 copayment for ophthalmological services. This item/service falls within the 
vision care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ophthalmological services 
provided on November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on March 02, 2023. 
 
You asked the Plan to pay for a home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. 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 
March 02, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each ambulance transportation provided on 
April 10, 2023, to April 12, 2023. 
 
You asked the Plan to waive the copayment for each ambulance transportation. You say that you disagree with 
the 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 $290 
copayment for ambulance services. 
 
You have been asked to pay a $290 copayment for each 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. The total amount you owe is $580 ($290 copayment + $290 copayment = $580). 
Therefore, we decided that the Plan does not have to waive the copayment for each ambulance transportation 
provided on April 10, 2023, to April 12, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a mammogram provided on February 28, 
2023. 
 
You asked the Plan to reduce the copayment for a mammogram. You say that you should only have a $15 
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 $75 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $75 copayment for a mammogram. This item/service falls within the in-network 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to reduce the copayment for a mammogram provided on February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on September 21, 2021, to 
November 14, 2022. 
 
You asked the Plan to pay for chiropractic care. You say that you are requesting reconsideration for the 
services provided. 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 
provided on September 21, 2021, to November 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an x-ray provided on March 20, 2023, a 
nerve conduction study, an EMG, and the diagnostic services provided on April 12, 2023. 
 
You asked the Plan to waive the cost share for an x-ray, a nerve conduction study, an EMG, and the diagnostic 
services. 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 which applies to outpatient diagnostic tests and 
therapeutic services and supplies. Your contract with the Plan also clearly says that you must pay 10% 
coinsurance for in-network x-rays, diagnostic procedures and tests, and diagnostic radiology services. 
 You have been asked to pay $25.74 towards your deductible for the x-ray provided on March 20, 2023. You 
have also been asked to pay $135.34 towards your deductible for the nerve conduction study and the EMG 
provided on April 12, 2023. You have also been asked to pay $105.64, which satisfies the deductible for the 
diagnostic services provided on April 12, 2023. The remaining allowed amount for the diagnostic services is 
$147.27. The items or services you asked the Plan to waive the cost share for fall within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is a $300 deductible which applies to outpatient diagnostic tests 
and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the 
time an x-ray, a nerve conduction study, an EMG, and the diagnostic services was received on March 20, 2023, 
to April 12, 2023.  
 
You have been asked to pay $14.73, which is 10% coinsurance of the remaining allowed amount for the 
diagnostic services provided on April 12, 2023 ($147.27 remaining allowed amount x 10% = $14.73). 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 waive the cost share for an x-ray provided on March 20, 2023, a nerve conduction 
study, an EMG, and the diagnostic services provided on April 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient observation 
provided on January 29, 2023. 
 
You asked the Plan to waive the copayment for an in-network inpatient observation. You say that you never 
went through the emergency room, just went to your inpatient room. You should not have to pay this large 
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 outpatient hospital services. 
 
You have been asked to pay a $110 copayment for an in-network inpatient observation. This item/service falls 
within the outpatient hospital 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 inpatient observation provided on January 29, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the chest x-ray and CT scan provided on 
May 12, 2023. 
 
You asked the Plan to waive the copayments for the chest x-ray and CT scan. You say that because of your 
kidney cancer the Plan should pay this in full. 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 $55 
copayment for each x-ray. Your contract with the Plan also clearly says that you must pay a $300 copayment for diagnostic imaging, including CT scans. 
 
You have been asked to pay a $55 copayment for the chest x-ray. You have also been asked to pay $195.94, 
which is less than the standard $300 copayment for the CT scan. These items/services fall within the outpatient 
diagnostic tests and therapeutic services benefit category. You have been asked to pay a total of $250.94 ($55 
copayment + $195.94 copayment = $250.94). 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 the chest x-
ray and CT scan provided on May 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test and a specialist 
office visit provided on February 23, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test and a specialist office visit. 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 $10 
copayment for outpatient diagnostic test/non-radiological diagnostic services and a $30 copayment for 
physician/practitioner services/specialist.  You have been asked to pay a $10 copayment for an outpatient diagnostic test and a $30 copayment for a 
specialist office visit. However, you are only being asked to pay $8.54 for the outpatient diagnostic test which 
is less than the required amount. Also, you are only being asked to pay $24.30 for the specialist office visit 
which is less than the required amount. The total amount you are being asked to pay is $32.84 ($24.30 + 8.54 = 
$32.84). 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 outpatient diagnostic test and a specialist 
office visit provided on February 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a wheeled walker provided on March 24, 
2023. 
 
You asked the Plan to waive the coinsurance for a wheeled walker. You say that you do not agree with the cost 
sharing amount. 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 10% 
coinsurance for in-network durable medical equipment (DME) and related medical supplies. 
 
You have been asked to pay 10% coinsurance for a wheeled walker. This item/service falls within the in-
network durable medical equipment (DME) and related medical 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 $7.59 ($75.93 
allowed amount x 10% = $7.59). Therefore, we decided that the Plan does not have to waive the coinsurance 
for a wheeled walker provided on March 24, 2023.