Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the second claim for Radiologic examination, femur 
provided on March 10, 2020. 
 
You asked the Plan to pay for Radiologic examination, femur; minimum 2 views (73552). You say that the 
Plan should pay this claim. The Plan denied your request. The Plan says this claim is a duplicate to the claim 
paid on March 24, 2020. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The record provided shows one radiological procedure interpretation 
of the femur x-ray was performed. Based on this information, we decided that Medicare rules for coverage of a 
second claim of Radiologic examination, femur; minimum 2 views (73552) have not been met. Therefore, we 
decided that the Plan does not have to pay for the second claim for Radiologic examination, femur provided on 
March 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for echocardiography (93306) provided on January 22, 2020. 
 
You asked the Plan to pay for the echocardiography. You say that you would like reconsideration because you 
are not able to bill globally. The Plan denied your request. The Plan says when a provider under the same tax 
identification number performs both the 26 and technical components of a code, they need to bill globally. 
 
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 93306 is not supported in the record. Specifically, the record indicates that the provider 
rendered both the professional and technical component of this service. This service should be billed globally. 
Based on this information, we decided that Medicare rules for coverage of the echocardiography have not been 
met. Therefore, we decided that the Plan does not have to pay for echocardiography (93306) provided on 
January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness exam provided on May 11, 2020. 
 
You asked the Plan to pay for the annual wellness exam. You say that you do not feel liable for the services. 
The Plan denied your request. The Plan says you exhausted your benefit for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the annual wellness exam have not been met. Review of the file shows that you had an annual 
wellness exam on February 3, 2020. Your EOC states that this is covered once every 12 months. Therefore, we 
decided that the Plan does not have to pay for the annual wellness exam provided on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99212) provided on 
October 11, 2019. 
 
You asked the Plan to waive the copayment 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 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 $35 
copayment for each specialist visit for Medicare-covered services.  
 
You have been asked to pay a $35 copayment for the specialist visit provided. 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 office visit (99212) provided on October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on February 25, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim was billed with an "always therapy" 
service which was not billed with the required therapy modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the outpatient services are not supported in the record. Specifically, the record shows that this 
claim includes CPT code 92526, which is an always therapy code. Therapy codes require a GN, GP or GO 
modifier. The submitted claim does not include the required modifier. Based on this information, we decided 
that Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the 
Plan does not have to pay for outpatient services provided on February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on March 8, 
2020. 
 
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 services provided to the enrollee on March 8, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the provision of materials for use in the home 
provided on May 6, 2020. 
 
You asked the Plan to waive the copayment for the provision of materials for use in the home. You say that you 
would rather go back to the lab each week to not be charged. The Plan denied your request. The Plan says that 
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. Your 
contract with the Plan says that enrollees must pay $0 copayment for lab services.  
 
You received the provision of materials for use in the home on May 6, 2020 from a provider billing as a 
laboratory. Therefore, the service is considered a laboratory service and you are not responsible to pay a 
copayment.  
 
The Plan says you must pay a $45 copayment for lab services. Based on the Plan contract, however, you cannot 
be asked to pay more than $0 copayment for lab services. Therefore, we decided that the Plan has to waive the 
copayment for the provision of materials for use in the home provided on May 6, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for multiple injectable drugs received on 
February 28, 2020. 
 
You asked the Plan to waive the coinsurance for multiple injectable drugs. You say that you cannot pay as 
these costs are astronomically high. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
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 Part B prescription drugs.  
 
You have been asked to pay $353.42, or 20% of the Plan-allowed amount of $1,767.09, for multiple injectable 
drugs. 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 multiple injectable drugs received on February 
28, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (abdomen and pelvis) provided to the enrollee 
on January 17, 2020. 
 
You asked the Plan to pay for the scan. You say that this should be paid for. The Plan denied your request. The 
Plan says the medical records indicate that CT scan of the abdomen was performed. 
 
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 74176 is "computed tomography, abdomen and pelvis; 
without contrast material." 
 
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 scan. Our reviewer says that the services 
at issue in this case were not supported by the medical records. Our physician reviewer found on the date of 
service at issue in this case, the enrollee had a CT of the chest and abdomen, not of the abdomen and pelvis. As 
such the codes which were appropriate were not 74176 (CT of the abdomen and pelvis) but rather CT of the 
chest without contrast (71250) and CT of the abdomen without contrast (74150). 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pay for the CT scan (abdomen and pelvis) provided to the enrollee on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services rendered by the out of network (OON) provider 
from January 10, 2020 to January 31, 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 services rendered by the out of network (OON) provider from January 10, 2020 to 
January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for arthrocentesis provided from December 
11, 2019 to December 31, 2019. 
 
You asked the Plan to waive the copayments for arthrocentesis. You say that you were not informed that you 
would owe a copayment for the injections. 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 $45 
copayment for specialist services. 
 
You received arthrocentesis on December 11, 2019, December 18, 2019 and December 31, 2019. Therefore, 
you are responsible to pay a $45 copayment per each service. The total amount you owe is: $45 (copayment) x 
3 (specialist services) = $135.   
 
You have been asked to pay the total copayment amount of $135 for arthrocentesis. Arthrocentesis falls within 
the physician/practitioner services, including doctor?s office visits 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 copayments for arthrocentesis provided from December 11, 2019 to December 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 4, 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 claim was not billed correctly. The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on November 25, 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 claim cannot be paid as billed due to a modifier issue. The Plan requested a 
corrected claim. 
 
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, code 81479-90 cannot be paid as billed due to a modifier error. Medicare billing criteria do not 
allow the use of this modifier and code combination. Therefore, we decided that the Plan does not have to pay 
for lab services provided to the enrollee on November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) and a shoulder-hand-wrist 
orthosis (L3960) provided to the enrollee on March 26, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the supplied documentation did not include a delivery ticket. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery to support medical necessity for the supplies provided in 
this case. There is no delivery ticket or proof of delivery. The record shows that the Plan made several attempts 
to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to 
pay for a wrist-hand orthosis (L3916) and a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on 
March 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that 
were issued on February 24, 2020. 
 
You asked the Plan to pay for the compression stockings. You say that the compression stockings should be 
covered. The Plan denied your request. The Plan says the stockings are not covered by Medicare, therefore not 
covered by the Plan. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6549 that were issued on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dermatology services provided from May 20, 2019 to 
November 20, 2019 by out of network (OON) providers. 
 
You asked the Plan to pay for dermatology services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the member's primary care physician did not refer these services. 
 
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 dermatology services provided from May 20, 2019 
to November 20, 2019 by out of network (OON) providers.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an ultrasound provided on June 5, 2020. 
 
You asked the Plan to waive the deductible for an ultrasound. You say that you disagree with the charges 
because they are a lot for a small test. 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. Your 
contract with the Plan says that there is a $750 deductible for outpatient hospital services.  
 
You received an ultrasound on June 5, 2020. The record shows that you had only paid $0 toward the $750 
deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $608.64.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
hospital services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible for outpatient hospital services. This cost sharing is a contractual obligation that had not been met at 
the time an ultrasound was received on June 5, 2020. Therefore, we decided that the Plan does not have to 
waive the deductible for an ultrasound provided on June 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection rendered on April 27, 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 procedure code 87633 is non-covered. 
 
We looked at the file and Medicare rules. The services at issue were billed with code 87633. This code is non-
covered by Medicare. Therefore, we decided that the Plan does not have to pay for the infectious agent 
detection rendered on April 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skin biopsy you had on March 6, 2020. 
 
You asked the Plan to waive the copayment for the skin biopsy. You say that these services were rendered in a 
doctor's office, so this cost sharing should be waived. The Plan denied your request. The Plan says these 
services were not rendered in a doctor's office - they were rendered at an outpatient hospital facility.  The plan 
says that you were charged this amount 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 a $250 
copayment for outpatient surgery services.  
 
You have been asked to pay a $250 copayment for the skin biopsy. The claim is clearly from a hospital, not 
from a doctor.  The address on the claim is for the hospital, not a doctor's office.  The actual services billed 
were outpatient hospital services, billed on an outpatient hospital claim form, not a physician claim Form.  For 
these reasons, the skin biopsy was performed at an outpatient hospital facility. 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 skin biopsy you had on March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 10, 2020, 
February 18, 2020, February 19, 2020 and March 11, 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 February 10, 2020, February 
18, 2020, February 19, 2020 and March 11, 2020.