Persius/hicric huggingface dataset:
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 4, 2020. 
 
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 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 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar sacral orthosis and knee orthosis provided to the 
enrollee on April 6, 2020. 
 
You asked the Plan to pay for the orthoses. You say that these items were medically necessary. The Plan denied 
your request. The Plan says that the medical records do no support the need for these items. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. 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 the lumbar sacral orthosis and 
knee orthosis provided to the enrollee on April 6, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on February 14, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization.  
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist (MFT) is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue is a Marriage Family Therapist (MFT).  
Medicare says that a Marriage Family Therapist (MFT) is not eligible to participate in the Medicare program. 
Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on February 14, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided on February 7, 2020 
through February 9, 2020. 
 
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the service billed. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the critical care services. Our reviewer says that CPT code 
99291 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical 
records provided for February 7, 2020, February 8, 2020 and February 9, 2020 note that 25 minutes was spent 
providing this service, therefore definition of CPT code 99291 has not been met and cannot be billed for this 
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 critical care services have not been met. Therefore, we decided that the Plan 
does not have to pay for critical care services (99291) provided on February 7, 2020 through February 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 17, 2020 by an out 
of network (OON) provider. 
 
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 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 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 January 17, 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 the WATS 3D (brush) biopsy testing coded as 88361, 88312, 
88305 and 88104 provided February 12, 2020. 
 
You asked the Plan to pay for the WATS 3D (brush) biopsy testing. You say that the WATS 3D method of 
screening and surveillance is included by the ASGE in their standards of practice guidelines and medically 
necessary for this enrollee. The Plan denied your request. The Plan says experimental or investigation services 
are not covered. 
 
The Plan must follow Medicare rules. The rules explicitly say that screening tests, with the exception of the 
few tests listed above, are not covered. The rules also say that experimental and investigational devices are not 
covered. 
 
We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the WATS 3D (brush) biopsy testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the WATS 3D (brush) biopsy testing coded as 88361, 88312, 88305 and 88104 provided 
February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided to the enrollee on February 6, 
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 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 podiatry services provided to the enrollee on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 20, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 
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 subsequent nursing facility care provided on March 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided on April 23, 
2020. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services were not pre-authorized or emergent. 
Network providers were 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 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 mental health services provided on 
April 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the ostomy supplies you received from 
March 17, 2020 through April 15, 2020. 
 
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that these are prosthetics, not 
durable medical equipment, so no cost sharing should apply. The Plan denied your request. The Plan says you 
were charged this coinsurance correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for prosthetics and related supplies.  
 
You have been asked to pay 20% coinsurance for the ostomy supplies. The ostomy supplies fall within the 
prosthetics and related 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 coinsurance for 
the ostomy supplies you received from March 17, 2020 through April 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided  
January 14, 2020 to January 20, 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 $350 
copayment for each Medicare-covered hospital stay.  
 
You have been asked to pay a $350 copayment for the Medicare-covered inpatient hospital stay. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. The record shows that 
you issued payment to the provider in the amount of $120, therefore your remaining balance is $230. 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 inpatient hospital care provided January 14, 2020 to 
January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on May 27, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit 
and you should not be responsible for the charges. 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 $10 
copayment for primary care provider visits. 
 
The medical records show that you received an office visit on May 27, 2020 that went beyond an annual 
wellness visit. Therefore, you are responsible to pay the $10 copayment.   
 
You have been asked to pay a $10 copayment for an office visit. An office visit 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 copayment for an office visit provided on May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for facet joint injections (64635, 64636) provided on February 5, 
2020. 
 
You asked the Plan to pay for facet joint injections. You say that this should be covered. The Plan denied your 
request. The Plan says this is included in the global surgical package of injections provided on January 29, 
2020. 
 
The Plan must follow Medicare rules. Medicare rules say that a postoperative period of 10 days applies to some 
minor surgeries. Two CPT modifiers were established to simplify billing for visits and other procedures which 
are furnished during the postoperative period of a surgical procedure, but which are not included in the 
payment for the surgical procedure. 
 
We looked at the file and Medicare rules. The record shows that facet joint injections (64625, 64636) were 
performed on January 29, 2020 and have a post-operative period of ten days. The procedures at issue were 
performed in this period and were not billed with modifiers that indicate they are separately payable. Based on 
this information, we decided that Medicare rules for coverage of facet joint injections have not been met. 
Therefore, we decided that the Plan does not have to pay for facet joint injections (64635, 64636) provided on 
February 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the facet denervation procedure you had on 
February 28, 2020. 
 
You asked the Plan to waive the copayment for the facet denervation procedure. You say that you were not 
aware that the facility where you had this procedure was an ambulatory surgical center. 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 $210 
copayment for services at an ambulatory surgical center.  
 
You have been asked to pay a $210 copayment for the facet denervation procedure. We have confirmed that the 
facility where you had this service is an ambulatory surgical center. 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 facet denervation procedure you had on February 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 6, 2020 to March 
5, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit (99213) and x-ray (73552). You say that you would like 
reconsideration because this service was for post-operation care. The Plan denied your request. The Plan says 
the services provided were outside the 90-day global fee schedule, were foreseen need, were not urgent or 
emergent and there was no 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 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 January 6, 2020 
to March 5, 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 the medical services provided on January 29, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services were not referred by a network provider or rendered in a participating 
facility. The Plan states that these services are not urgent or emergent, nor were they 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 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 29, 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 the Guardant360 Plasma-Based Comprehensive Genomic 
Profiling testing provided on April 22, 2020 billed with multiple line items of different CPT codes. 
 
You asked the Plan to pay for the Guardant360 Plasma-Based Comprehensive Genomic Profiling testing 
provided on April 22, 2020 billed with multiple line items of different CPT codes.. You say that this should not 
be denied as experimental as this is a proven test which is supported for this patient. The Plan denied your 
request. The Plan says on review, it was found that no payment can be made for this testing because the 
provider is unbundling when there is a single CPT code which describes this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to report the Guardant360 testing, one 
unit of code 81479 should be reported with the appropriate DEX Z-code.  
 
As there is a single CPT code which describes this testing, the rule for coverage of this testing as billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 Plasma-Based 
Comprehensive Genomic Profiling testing provided on April 22, 2020 billed with multiple line items of 
different CPT codes.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
May 4, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy for the enrollee's condition. The Plan denied your request. 
The Plan says the denial of payment for this testing is correct, because this testing was not billed with the 
appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service May 4, 2020.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
comprehensive genomic profile (CGP) testing provided on May 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 27, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for drug test. You say that you provided service without doing prior analysis of the 
enrollee's coverage. 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 there was not a valid referral for this service. 
 
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 January 27, 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 28, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that you do not accept walk0ins and do not have 
information on the enrollee's insurance requirements, limitations, or conditions. The Plan denied your request. 
The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the 
Plan and the referring 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 January 28, 2020 
by an out of network (OON) provider.