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

 
We decided that the Plan does not have to waive the copayment for wound care services provided on June 28, 
2023. 
 
You asked the Plan to waive the copayment for wound care 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 $365 
copayment for outpatient hospital services. 
 
You have been asked to pay a $365 copayment for wound care services. 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. However, since the allowed amount is less than the standard copayment, you only owe 
$335.28. Therefore, we decided that the Plan does not have to waive the copayment for wound care services 
provided on June 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each wound debridement service provided 
on March 31, 2023, to June 09, 2023. 
 
You asked the Plan to waive the copayment for each wound debridement service. You say that you previously 
only paid a $40 copayment 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 a $250 
copayment for in-network outpatient surgery. 
 
You have been asked to pay a $250 copayment for each wound debridement service. This item/service falls 
within the in-network outpatient surgery 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. You have been asked to pay a total of $2,500 ($250 copayment per service 
x 10 services = $2,500). Therefore, we decided that the Plan does not have to waive the copayment for each 
wound debridement service provided on March 31, 2023, to June 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment, and a take home supply of 
methadone provided on June 26, 2023. 
 
You asked the Plan to pay for medication assisted treatment, and a take home supply of methadone. You say 
that a referral or authorization is not required. 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 medication assisted 
treatment, and a take home supply of methadone provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 14, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the services 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 laboratory services 
provided on March 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a revision of shoulder arthroplasty (23474). 
 
You asked the Plan to pre-approve a revision of shoulder arthroplasty. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested service is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 a revision of shoulder arthroplasty. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative-care measures is not evident in the case record. The enrollee has had 
pain for 2 weeks as of May 25, 2023, and has trialed medications. No other conservative measures in forms of physical therapy etc. have been attempted. Moreover, the June 7, 2023, computed tomography scan of the right 
shoulder did not demonstrate any hardware complications. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a revision of shoulder arthroplasty have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a revision of shoulder arthroplasty (23474).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network urgent care visit 
provided on March 26, 2023. 
 
You asked the Plan to waive the copayment for an out-of-network urgent care visit. You say that all Covid 
related bills should be covered. You should not have a copayment at all. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for urgently needed services. 
 
You have been asked to pay a $45 copayment for an out-of-network urgent care visit. This item/service falls 
within the urgently needed 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 out-of-network urgent care visit provided on March 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for excision, malignant lesion including margins provided on 
June 28, 2023. 
 
You asked the Plan to pay for excision, malignant lesion including margins. You say that this service is 
supported in the records. 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 excision, malignant 
lesion including margins provided on June 28, 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 
July 07, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you feel you 
should not be responsible for a copayment because you only went for a scan and was given additional 
unnecessary tests. 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 July 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedure and related services provided on 
March 29, 2023, to March 30, 2023. 
 
You asked the Plan to pay for therapeutic procedure and related services. You say that the services 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 therapeutic procedure 
and related services provided on March 29, 2023, to March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit provided on June 29, 2023. 
 
You asked the Plan to pay for a psychotherapy 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 psychotherapy visit 
provided on June 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 03, 2023. 
 
You asked the Plan to pay for the genetic testing. 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 genetic testing 
provided on May 03, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on January 27, 2023. 
 
You asked the Plan to pay for CxBladder testing. You say that this was medically necessary. The Plan denied 
your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that non-coverage has been reaffirmed for CPT codes 
0012M and 0013M for CxBladder. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CxBladder testing have not been met. The service at issue is non-covered. Therefore, we decided 
that the Plan does not have to pay for CxBladder testing (0012M) provided on January 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
February 22, 2023, to February 24, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. 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 $250 
copayment for inpatient hospital care. 
 
You have been asked to pay a $250 copayment for inpatient hospital care. 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. The total amount you are being asked to pay is $500 ($250 x 2 days = $500). Therefore, 
we decided that the Plan does not have to waive the copayment for inpatient hospital care provided on February 
22, 2023, to February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on September 23, 2022. 
 
You asked the Plan to pay for ophthalmological services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for ophthalmological 
services provided on September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for immune globulin injections provided on 
May 26, 2023. 
 
You asked the Plan to waive the coinsurance for immune globulin injections. You say that you were not told 
how much you would have to pay. 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 Part B drugs that are administered by a provider. 
 
You have been asked to pay 20% coinsurance for immune globulin injections. This item/service falls within the 
Part B drugs that are administered by a provider 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 immune globulin injections provided on May 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0481 provided on March 23, 2023. 
 
You asked the Plan to pay for procedure code G0481. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported 
 The Plan must follow Medicare rules. Medicare rules say while a physician order is not required to be signed, 
the physician must clearly document, in the medical record, the intent that the test be performed. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, medical records submitted 
do not include an order that specifically list what test(s) are to be performed in the custom panel. Based on this 
information, we decided that Medicare rules for coverage of procedure code G0481 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code G0481 provided on March 23, 
2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from August 
12, 2022, to August 31, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our 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 the services. Our reviewer says that the services at issue 
in this case were not supported by the medical records. Our reviewer found that the provided records in this 
case do not contain physician documentation of an active diagnosis of CVA (cerebrovascular accident), TIA 
(transient ischemic attack) or stroke.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services rendered from August 12, 2022, to August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 
15, 2023. 
 
You asked the Plan to waive the copayment for 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 $45 
copayment for physician/practitioner services/specialist officevisit. 
 
You have been asked to pay a $45 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist officevisit 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 specialist office visit provided on June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99214) 
rendered on February 8, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not show a significantly different and separately identifiable evaluation and 
management service.  
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 99214 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the office notes do not support 
CPT 99214, as the enrollee's conditions were stable, with no additional procedures, orders, or medications. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for evaluation and management services (procedure code 99214) rendered on February 8, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy provided on June 20, 2023. 
 
You asked the Plan to pay for occupational therapy. You say that you are requesting a 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 occupational therapy 
provided on June 20, 2023.