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

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on October 2, 
2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for physician services provided to the enrollee on October 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for health club membership fee's. 
 
You asked the Plan to pay for health club membership fee's. You say that your submission was rejected 
because you mistakenly put 2019 on the claim form and it should have been 2018 and you feel that this should 
be paid. The Plan denied your request. The Plan says based on the review of the submitted proof of payment, 
the $250 health and wellness benefit was already reimbursed. Duplicate payment would result in overpayment. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan will reimburse up to 
$250 each calendar year towards your cost for membership in a qualified health club or fitness facility. 
 
The Plan's rules for coverage of gym benefits have not been met because based on the review of the submitted 
proof of payment, the $250 Wellness benefit was already reimbursed. Duplicate payment would result in 
overpayment. Therefore, we decided that the Plan does not have to pay for health club membership fee's.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 
1, 2020 to April 29, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration because this 
claim is being processed episodic and these are per visit claims. The Plan denied your request. The Plan says 
payment for this service is not allowed because it was billed with an incorrect type of bill code.  
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim 
was submitted with an invalid type of bill code. Therefore, we decided that the Plan does not have to pay for 
the home health services provided to the enrollee from April 1, 2020 to April 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 5, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the office visit (99214) and behavioral assessment (96127). You say that you 
would like reconsideration because the services rendered were medically necessary. The Plan denied your 
request. The Plan says this provider is outside of the member's network of providers and prior authorization 
was not obtained from the Plan. 
 
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 has network providers 
available who can provide 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 medical services provided on August 5, 2019 
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from March 
3, 2020 through March 5, 2020. 
 
You asked the Plan to pay for inpatient hospital care. You say that the stay was medically necessary. The Plan 
denied your request. The Plan says prior approval was not obtained for the hospital admission. 
 
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. 
 
 Prior approval was not obtained for the hospital admission. 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. 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 inpatient hospital care provided to the enrollee from March 3, 2020 through March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the hemodialysis services provided from 
January 8, 2020 to January 31, 2020. 
 
You asked the Plan to waive the coinsurance for the hemodialysis services. You say that you should not be 
charged because kidney care is covered by insurance. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
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 Medicare-covered benefits.  
 
You have been asked to pay $56 which is 20% of the allowed amount for the hemodialysis services on each 
date of service. The allowed amount is $280. ($280 x 20% = $56). ($56 + $56 = $112). The hemodialysis 
services fall within the Services to Treat Kidney Disease 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 the hemodialysis services provided from January 8, 2020 to 
January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special services coded 99199, the IV tubing extension set 
coded S1015, and the infection control supplies coded S8301 provided on March 3, 2020. 
 
You asked the Plan to pay for the special services, the IV tubing extension set, and the infection control 
supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the services billed are not payable. 
 
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 codes 99199, S1015, and S8301 are not supported in the medical record. Specifically, code 
99199 are not to be used on claims billing for non-covered outpatient intravenous insulin therapy (OIVIT) and 
any services comprising an OIVIT regimen when furnished pursuant to an OIVIT regimen. Therefore, 99199 is 
not payable as billed. In addition, codes S1015 and S8301 have status codes of "I". A status code of I means 
that these codes are not payable by Medicare. Medicare uses another code for reporting of, and payment of 
these services. Based on this information, we decided that Medicare rules for coverage of the special services, 
the IV tubing extension set, and the infection control supplies have not been met. Therefore, we decided that 
the Plan does not have to pay for the special services coded 99199, the IV tubing extension set coded S1015, 
and the infection control supplies coded S8301 provided on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound debridement provided on May 13, 
2020. 
 
You asked the Plan to waive the copayment for wound debridement. You say that the enrollee met the MOOP 
amount for the year and should not be responsible for the charges. The Plan denied your request. The Plan says 
the claims were processed correctly and the enrollee is being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $225 copayment for outpatient surgery.  
 
The enrollee received wound debridement on May 13, 2020. The record shows that the enrollee had only paid 
$4,057.94 at the time services were rendered. Therefore, the enrollee is responsible to pay $42.06, which is less 
than the $225 copayment.  
 
The enrollee has been asked to pay $42.06 for wound debridement. Wound debridement falls within the 
outpatient surgery benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
wound debridement provided on May 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on March 11, 2020. 
 
You asked the Plan to pay for the testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 the testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z Code identifier should be entered adjacent in the 
comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
testing provided on March 11, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee out of 
network on March 11, 2020. 
 
You asked the Plan to pay for out of network providers. You say that this claim should be paid. The Plan 
denied your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for outpatient mental health care provided to the enrollee out of network on March 11, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on March 16, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services you received from January 6, 2020, to February 
21, 2020. 
 
You asked the Plan to pay for the services. You say that you were not aware these providers opted out of 
Medicare. The Plan denied your request. The Plan says this provider opted out of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the services you received from January 6, 2020, to February 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 and G0480 provided on 
January 13, 2020. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 codes 80307 and G0480 are not supported in the medical record. Specifically, the 
documentation submitted did not include a valid physician order/lab requisition or medical records signed by 
the ordering physician for the billed tests. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the drug testing coded 80307 and G0480 provided on January 13, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on January 8, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for out of network providers.. You say that this claim should be paid. The Plan 
denied your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 has network providers 
available who can provide 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 outpatient mental health services provided on 
January 8, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
August 21, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for out of network physician services provided to the enrollee on August 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the 
enrollee from January 28, 2020 through February 4, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing the 
member's cost-share responsibility for the services the member received. The Plan denied your request. The 
Plan says the claim was processed accordingly with the member's 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows that the enrollee was admitted on January 28, 2020 and discharged on February 4, 
2020. The enrollee was asked to pay a $270 copayment per day from January 28, 2020 through February 1, 
2020, days 1-5 of their inpatient stay. There were no copayment charges from February 2, 2020, day 6 of their 
inpatient hospital care until the enrollee's day of discharge February 4, 2020. Per your contract there is a $270 
copayment per day required for days 1-5. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
inpatient hospital care provided to the enrollee from January 28, 2020 through February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing.
 
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 this test should be reported with CPT 81479. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 laboratory testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation and incisional biopsy provided 
on February 18, 2020 and February 19, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation and incisional biopsy. You say that you weren't 
advised the provider was considered privately contracted. You say that the claim should be paid. The Plan 
denied your request. The Plan says payment cannot be issued for services performed by a provider who has 
opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the periodic oral evaluation and incisional biopsy provided on February 18, 2020 and February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 27, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab test. You say that this test was ordered by the treating physician to determine 
effective treatment planning for the enrollee. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because this provider is out-of-network with the Plan and the ordering 
provider is also out-of-network with the Plan. 
 
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 has network providers 
available who can provide 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 medical services provided on April 27, 2019 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out of network 
(OON) provider on October 25, 2019. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were provided by an out of 
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered by the out of network (OON) provider on October 25, 
2019.