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

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network 
(OON) provider on March 26, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered 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 service 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 this service. Therefore, we decided that the Plan does not 
have to pay for the office visit (99214) rendered by the out of network (OON) provider on March 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunohistochemistry or immunocytochemistry and the 
immunofluorescence services provided on December 18, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services received are not a covered benefit when 
provided by an OON provider. 
 
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 immunohistochemistry or 
immunocytochemistry and the immunofluorescence services provided on December 18, 2019 by an out of 
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital outpatient clinic visit (G0463) 
provided on March 10, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $400 
copayment for surgery or services provided to you at an outpatient hospital, including but not limited to 
hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay $129.47 for the hospital outpatient clinic visit provided. This is the Plan allowed 
amount, which is less than the applicable copayment. 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 
the hospital outpatient clinic visit (G0463) provided on March 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance, bitewings, and periodic oral 
evaluation provided on February 26, 2020. 
 
You asked the Plan to pay for the periodontal maintenance, bitewings, and periodic oral evaluation. You say 
that your 2020 Annual Notice of Changes states that any licensed dental provider may provide services. The 
Plan denied your request. The Plan says the services were rendered by a Medicare opt out provider. The Plan 
also says that charges incurred by Medicare opt out providers will not be reimbursed. 
 
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 periodontal maintenance, bitewings, and periodic oral evaluation provided on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmic diagnostic imaging provided on 
March 2, 2020. 
 
You asked the Plan to waive the copayment for ophthalmic diagnostic imaging. You say that you were told that 
you would only owe the office visit copayment. The Plan denied your request. The Plan says the claims were 
processed correctly and you are 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). Your contract with the Plan clearly says that you must pay a $50 
copayment for all other diagnostic procedures and tests.  
 
You have been asked to pay the total allowed amount of $46.06, which is less than the $50 copayment for 
ophthalmic diagnostic imaging. Ophthalmic diagnostic imaging 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 copayment for 
ophthalmic diagnostic imaging provided on March 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the ultrasound of the head and neck 
(76536) provided on May 23, 2020. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 
$110.00 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed 
in a physician's office or at a free-standing facility (such as a radiology center of medical clinic).  
 
You have been asked to pay a $107.02 copayment for the Medicare-covered radiological diagnostic service 
provided. This is the Plan allowed amount, which is less than the applicable copayment. 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 adjust the copayment for the ultrasound of the head and neck (76536) provided on May 23, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for a crown (D2791) provided on February 5, 2020. 
 
You asked the Plan to pay the full cost for a crown. You say that this should be covered. The Plan denied your 
request. The Plan says you exceeded the annual limit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers dental 
services up to a $1,000 annual maximum. 
 
We looked at the file, and Medicare rules. The record shows that you reached your annual maximum with the 
portion of this charge paid by the plan. Therefore, we decided that the Plan does not have to pay the full cost 
for a crown (D2791) provided on February 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a behavioral health inpatient admission provided from April 
18, 2020, through May 4, 2020. 
 
You asked the Plan to pay for the behavioral health inpatient admission. The Plan denied your request. The 
Plan says prior authorization was not obtained by the provider or the facility. 
 
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 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 a behavioral health inpatient admission provided from April 18, 
2020, through May 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on June 17, 2020. 
 
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physical therapy services. 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 physical therapy services provided on June 17, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient clinic visit you had at an 
outpatient hospital facility on June 8, 2020. 
 
You asked the Plan to waive the copayment for the outpatient clinic visit. You say that you think these charges 
are excessive. The Plan denied your request. The Plan says you were assessed this copayment correctly.  The 
Plan says that the allowed amount for this clinic visit is less than your copayment obligation, so you are 
responsible for the full amount ($129.47). 
 
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 $400 
copayment for surgery or other services provided to you at an outpatient hospital.  
 
You have been asked to pay the full amount ($129.47) for this visit because it is less than the $400 copayment. 
Because you had this visit at an outpatient hospital facility, the outpatient hospital benefit category applies. 
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 the outpatient clinic visit you had at an outpatient hospital 
facility on June 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on September 18, 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 records provided do not contain a valid physician's order. The Plan states that the 
submitted Laboratory Requisition indicates that Comprehensive Panel was requested. The submitted 
documentation does not itemize what tests are included in this panel; therefore, the billed code cannot be 
verified. It is noted multiple attempts were made to obtain additional information from the provider. 
 
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 records provided do not support 
the services billed. Medicare rules for coverage of this service have not been met. Therefore, we decided that 
the Plan does not have to pay for drug testing provided to the enrollee on September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit and femur x-ray provided on July 
28, 2020 by an OON provider. 
 
You asked the Plan to pay for the outpatient office visit and femur x-ray. You say that the services were 
necessary. The Plan denied your request. The Plan says the service was rendered by a non-contracted provider. 
The Plan also says that prior authorization was not obtained. 
 
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 outpatient office visit and femur x-ray 
provided on July 28, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided. 
 
You asked the Plan to pay for the first intraoral periapical x-ray. You say that the day before your cleaning you 
lost a filling. You also say that you asked if the service would be covered by your insurance, and were told yes. 
The Plan denied your request. The Plan says this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first 
intraoral periapical x-ray provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 29, 2020 by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee received lab work from the 
facility and left. You also say that the enrollee was not seen by the provider. The Plan denied your request. The 
Plan says the service was rendered by a non-contracted provider. The Plan also says that prior authorization 
was not obtained. 
 
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 laboratory services provided on May 29, 2020 
by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory assays of carbamazepine, clozapine, digoxin, 
haloperidol, levetiracetam, and topiramate provided on March 5, 2020. 
 
You asked the Plan to pay for the lab assays of the drugs noted. You say that this testing should be covered due 
to medical necessity. The Plan denied your request. The Plan says the codes at issue are not supported by the 
records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code billed not supported in the medical record. Specifically, these codes refer to testing 
which requires a plasma or serum sample, which requires a blood draw. The documentation only shows that a 
urine sample was taken. Based on this information, we decided that Medicare rules for coverage of the lab 
assays of the drugs noted have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory assays of carbamazepine, clozapine, digoxin, haloperidol, levetiracetam, and topiramate provided on 
March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paring or cutting of a benign hyperkeratotic lesion 
(11056) and the nail debridement (11721) rendered by the out of network (OON) provider on June 8, 2020. 
 
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 rendered 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 paring or cutting of a benign hyperkeratotic lesion (11056) and the nail 
debridement (11721) rendered by the out of network (OON) provider on June 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 genetic profiling panel provided on May 
11, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that this testing is helpful for targeted 
treatments and should be covered. The Plan denied your request. The Plan says this testing is not covered for an 
enrollee without non-small cell lung cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is covered for patients with 
stage IIIB or IV NSCLC. 
 
The documentation provided shows that the enrollee has carcinoma of unknown primary and no diagnosis of 
NSCLC. Therefore, we decided that the Plan does not have to pay for the Guardant360 genetic profiling panel 
provided on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing provided on December 26, 2019. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the Cxbladder test is considered experimental/investigational as a screening test for urothelial 
cancer. Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of 
the results of Cxbladder testing. Urinary biomarker tests such as Cxbladder give significant false-negative 
results in patients with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for 
low-stage and low-grade tumors. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Cxbladder testing provided on December 26, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided to the enrollee under codes 80157, 
80177, 80201, 80162, 80159 and 80173.  
 
You asked the Plan to pay for drug testing provided to the enrollee. You say that this claim should be paid. The 
Plan denied your request. The Plan says while a portion of this testing was paid, codes 80157, 80177, 80201, 
80162, 80159 and 80173 could not be paid based on the specimen type that was reported to have been taken. 
The Plan states this testing is performed on blood specimen. The Plan states the medical records indicate the 
specimen type collected was urine. 
 
The Plan must follow Medicare rules. The rules state that providers must submit claims with the correct codes. 
In this case, the claim submitted had billing errors regarding the codes submitted and their relationship to the 
type of specimen collected. Medicare billing criteria were not met. Therefore, we decided that the Plan does not 
have to pay for codes 80157, 80177, 80201, 80162, 80159 and 80173.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (S9338) provided. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee 
Schedule indicates that the code in question is not valid for Medicare purposes."  
 
We looked at the file and Medicare rules. Code S9338 is assigned a status indicator of ?I? under the Physician 
Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for 
reporting of, and payment for, these services. 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 the 
services (S9338) provided.