Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
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.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammography services (77067, 77063) provided on 
August 19, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services were 
paid. 
 
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 an additional unit of CPT codes 77067 and 77063 is not supported in the medical record. 
Specifically, the records show that one unit of CPT 77067 and 77063 was provided on the date of service in 
question, which was previously processed and paid by the Plan. Additional units are not supported. 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 mammography services (77067, 77063) provided on August 
19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Face-Down Recovery System purchased on 
August 5, 2020. 
 
You asked the Plan to reimburse you for the Face-Down Recovery System. You say that the recovery chair was 
medically necessary after surgery. The Plan denied your request. The Plan says face-down recovery systems 
are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Medicare does not 
cover Face-Down Recovery Systems. Therefore, we decided that the Plan does not have to reimburse you for 
the Face-Down Recovery System purchased on August 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 31237) provided on September 24, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 
cannot be verified. 
 
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 31237 is "Nasal/sinus endoscopy, surgical; with biopsy, 
polypectomy or debridement (separate procedure)". 
 
We asked our coding 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 use 
of CPT code 31237 is not supported by the records provided. Our coding reviewer found that the 
documentation did not include a report for CPT 31237 for date of service September 24, 2020 to confirm 
procedure was performed on this date of service. 
 
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 the services (CPT 31237) provided on September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 5, 2020. 
 
You asked the Plan to pay for the physician's 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 
physician's 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 physician's services provided on August 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with biopsy provided on 
October 28, 2020. 
 
You asked the Plan to waive the copayment for the colonoscopy with biopsy. You say that the doctor stated 
this would be a regular screening. The Plan denied your request. The Plan says you were charged this 
copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for Outpatient Surgery.  
 
You have been asked to pay a $250 copayment for the colonoscopy with biopsy. The screening colonoscopy 
turned into an outpatient surgery when polyps were removed. The colonoscopy with biopsy falls within the 
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. Therefore, we decided that the Plan does not have to waive the copayment for the colonoscopy with 
biopsy provided on October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and the unspecified 
preventive service (D1999) provided on September 21, 2020. 
 
You asked the Plan to pay for the dental services. You say that the dentist only did a simple cleaning. You say 
that the dentist charged you for a different service. You also say that you specifically told them that you only 
wanted the 6 month cleaning covered by your insurance. The Plan denied your request. The Plan says 
periodontal maintenance is not listed as a covered service. The Plan also says that unspecified preventive 
service is not listed as a covered service. 
 
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 
periodontal maintenance (D4910) and the unspecified preventive service (D1999) provided on September 21, 
2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on August 11, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because all 
of the member's treatment options require molecular testing. The Plan denied your request. The Plan says this 
service is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that one unit of CPT code 81479 is used to report 
Guardant360 testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Specifically, this service has not been reported with the 
appropriate CPT code. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing 
provided on August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services rendered on September 2, 
2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that modifier AS is billed to indicate that a PA, NP or CNS 
served as the assistant at surgery. Modifier 80, 81 or 82 must also be billed when modifier AS is billed. 
 
We looked at the file and Medicare rules. The provider billed procedure code 60219 with modifier AS. 
Required modifier 80, 81, or 82 was not billed with the claim. The claim was also not billed with the primary 
surgeon's claim. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services 
rendered on September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the prophylaxis 
(D1110), the bitewing x-ray (D0274), the initial periapical x-ray (D0220), and the additional periapical x-ray 
(D0230) provided on January 13, 2020. 
 
You asked the Plan to pay for the dental services. You say that the Plan changed its name at the beginning of 
2020. You say that you were advised that you did not need to take any actions and your health plan would be 
the same. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says the 
provider in this case is out of network. The Plan also says that dental services that you receive out of network 
are 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, supplemental dental services must be 
received from a participating provider in order to be covered by the plan. Therefore, we decided that the Plan 
does not have to pay for the periodic oral evaluation (D0120), the prophylaxis (D1110), the bitewing x-ray 
(D0274), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on January 
13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a denosumab injection provided on March 
13, 2020. 
 
You asked the Plan to waive the coinsurance for Part B drug. You say that the provider did not catch your 
cancer prior to you being able to have appropriate treatment. The Plan denied your request. The Plan says the 
coinsurance amount you are being charged is correct. 
 
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 chemotherapy drugs. The allowed amount of this claim is $4,047.52, resulting in a coinsurance 
obligation of $809.50. 
 
You have been asked to pay 20% coinsurance for Part B drug. Part B drug falls within the Medicare Part B 
Prescription Drugs 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 a denosumab 
injection provided on March 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for routine electrocardiogram (ECG) services 
(9300) provided October 13, 2020. 
 
You asked the Plan to waive the copayment for the ECG services. You say that you should not have to pay the 
additional $10 copay since the EKG was rendered on the same day as your physical. The Plan denied your 
request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of 
Coverage. 
 
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 per 
for Medicare covered laboratory tests. You will only pay one copayment per day even if multiple lab tests are 
performed. for Outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $10 per for Medicare covered laboratory tests. You will only pay one copayment 
per day even if multiple lab tests are performed. for the ECG services. the ECG services 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 routine electrocardiogram (ECG) services (9300) provided October 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hip x-ray with pelvis provided on 
October 14, 2020. 
 
You asked the Plan to waive the copayment for the hip x-ray with pelvis. You say that you don't remember 
having this x-ray on this date of service. The Plan denied your request. The Plan says you were charged this 
copayment 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 $40 
copayment for Outpatient Diagnostic Tests.  
 
You have been asked to pay a $40 copayment for the hip x-ray with pelvis. The hip x-ray falls within the 
Outpatient Diagnostic Tests benefit category. The record shows you had a hip x-ray with pelvis on this date of 
service. 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 hip x-ray with pelvis provided on October 
14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the removal of skin and tissue (11042) 
provided on May 12, 2019, to July 7, 2020. 
 
You asked the Plan to waive the copayment for the removal of skin and tissue. You say that you would like the 
copayment for these services waived. The Plan denied your request. The Plan says the copayment has 
processed correctly in this case. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient hospital services.  
 
You have been asked to pay a total cost share of $1250 for the removal of skin and tissue ($250 copayment x 5 
outpatient visits). the removal of skin and tissue 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 the removal of skin and tissue (11042) provided on May 12, 
2019, to July 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic testing provided on November 
20, 2019. 
 
You asked the Plan to pay for the GeneSight Psychotropic testing. You say that you would like reconsideration 
because this testing is medically necessary. The Plan denied your request. The Plan says the documentation 
submitted does not include a valid physician order for the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services in the medical record, is required for Medicare-covered laboratory services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the GeneSight Psychotropic testing have not been met. Specifically, the record does not include a 
physician order or clear intent to order the specific lab services in the medical record. Therefore, we decided 
that the Plan does not have to pay for the GeneSight Psychotropic testing provided on November 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the IV tubing (S1015) and infection control supplies (S8301) 
provided on July 7, 2020. 
 
You asked the Plan to pay for the IV tubing and infection control supplies. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT codes S1015 
and S8301 have status indicators of I and are not valid for Medicare purposes. 
 
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 S1015 and S8301 are not supported in the record. Specifically, per the Physician Fee 
Schedule, CPT codes S1015 and S8301 have a status indicator of I. This means that CPT codes S1015 and 
S8301 are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the IV tubing and infection control supplies have not been met. Therefore, we decided that the Plan 
does not have to pay for the IV tubing (S1015) and infection control supplies (S8301) provided on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 10, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician visit. You say that your provider depends on the facility to verify 
eligibility and obtain authorization. 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 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on August 10, 2020 
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility services provided to the enrollee on June 
18, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that the doctor was not responsible to get authorization. 
The Plan denied your request. The Plan says preapproval was not received prior to the services be performed. 
 
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 nursing facility services provided to the 
enrollee on June 18, 2020, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 14, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says utilization of network providers is required 
when possible and available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on January 14, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for intravenous infusion visits on August 25, 
2020, and August 31, 2020 and a Ferumoxytol injection on August 31, 2020. 
 
You asked the Plan to waive the cost-sharing for intravenous infusion visits on August 25, 2020, and August 
31, 2020 and a Ferumoxytol injection on August 31, 2020. You say that these services were charged 
incorrectly. The Plan denied your request. The Plan says these services processed 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 Medicare Part B-covered drugs and a $150 copayment for each Medicare-covered outpatient 
hospital facility visit, clinic, outpatient treatment room, observation room or outpatient surgery services. 
 
You have been asked to pay a $150 copayment for each intravenous infusion visit on August 25, 2020, and 
August 31, 2020, and 20% coinsurance for a Ferumoxytol injection on August 31, 2020. 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-sharing for intravenous infusion visits on August 25, 2020, and August 31, 
2020 and a Ferumoxytol injection on August 31, 2020.