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

 
We decided that the Plan does not have to pay for laboratory services provided on March 5, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that this provider is an independent laboratory 
they do not have direct access or interaction with the member and that it is the responsibility of the referring 
physician to obtain prior authorization. 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 and the referring provider are not network providers with the Plan. The Plan 
did not pre-approve the laboratory 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 laboratory services provided on March 5, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99233, 99070) provided on April 9, 2018. 
 
You asked the Plan to pay for hospital care. You say that this should be covered because your enrollment had 
not ended. The Plan denied your request. The Plan says proof of payment was not received. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
 
We looked at the file and Medicare rules. No proof of payment or medical records have been submitted. 
Without this information, it cannot be determined if Medicare coverage criteria have been met. Based on this 
information, we decided that Medicare rules for coverage of hospital care have not been met. Therefore, we 
decided that the Plan does not have to pay for hospital care (99233, 99070) provided on April 9, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
provided on March 10, 2020. 
 
You asked the Plan to pay for the endosteal implant. You say that the dentist office told you that the implant 
would be covered at 50%, based on a call the office made to the Plan. The Plan denied your request. The Plan 
says this service is not covered under your contract under any normal circumstances. The Plan also says the call 
with your dentist's office was reviewed, and no misinformation was given. 
 
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 
surgical placement of implant body: endosteal implant provided on March 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 26, 
2019 through November 30, 2019 provided by an in-network provider. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that if you would have been 
transferred to rehab one day later, you  would have probably just stayed in the hospital for continuous 
treatment. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 
EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows that you were admitted on November 26, 2019 and discharged on November 30, 
2019. You were asked to pay a $295 copayment per day from November 26, 2019 through November 29, 2019, 
days 1-4 of your inpatient hospital care. You were discharged on November 30, 2019 and there was no 
copayment charge for the day of discharge. Per your contract there is a $295 copayment per day required for 
days 1-4 for in-network inpatient hospital care. 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 inpatient 
hospital care from November 26, 2019 through November 30, 2019 provided by an in-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a chest x-ray (71046) provided February 
25, 2019. 
 
You asked the Plan to waive the copayment for the chest x-ray. You say that the copayment should be waived. 
The Plan denied your request. The Plan says the correct copayment 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 a $10 
copayment for x-rays in a Primary Care Office.  
 
You have been asked to pay a $10 copayment for the chest x-ray. The chest x-ray falls within the x-rays in a 
Primary Care Office 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 a chest x-ray (71046) 
provided February 25, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for two (2) ophthalmic ultrasounds (CPT Code 
76511 x 2) on February 26, 2020. 
 
You asked the Plan to waive the copayment for the ultrasounds. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Per your plan benefits there is $110 copayment for each Medicare-covered radiological diagnostic service. 
After review of services you have received two Ophthalmic ultrasounds on date of service February 26, 2020. 
The Medicare-allowed amount for the ultrasounds is less than the set $110 copayment per ultrasound; 
therefore, you have been asked to pay the lesser amount of $122.89 for the ultrasounds instead of a $220 
copayment.  
 
Please be aware that cost share for CPT code 76511-RT should be $64.08, the Plan incorrectly processed and 
applied a cost share of $58.81. The cost share should have been the higher rate however because the Plan made 
the error in processing, the Plan will not be charging you the additional cost share for services. 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 two (2) ophthalmic ultrasounds (CPT Code 76511 x 2) on February 
26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for MSI analysis and NRAS mutation genetic testing provided to 
the enrollee on July 12, 2019. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim was processed correctly per how the provider billed for the services. 
 
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 the documentation in the case file is insufficient to demonstrate that the coverage criteria for NRAS 
mutation genetic testing and MSI analysis were met in this case. There were no clinical records in the case file. 
 
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 MSI analysis and NRAS mutation genetic testing provided to the enrollee on July 12, 2019.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing services (CPT 80307) provided to the enrollee on May 23, 
2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the documentation submitted did not include laboratory results for the billed service. 
 
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 80307 is "Drug test(s), presumptive, any number of drug 
classes, qualitative; any number of devices or procedures, by instrument chemistry and analyzers (e.g.,  
utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and 
mass spectrometry either with or without chromatography, (DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-
MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service." 
 
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 services. Our reviewers say that the 
services at issue in this case were supported by the medical records. Our physician reviewer found the 
laboratory submitted a valid/signed physician laboratory requisition form and lab results. The review has 
determined that the records support the denied codes. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
drug testing services (CPT 80307) provided to the enrollee on May 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 23, 2019. 
 
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 April 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic office visit (99201) provided February 10, 
2020. 
 
You asked the Plan to pay for a chiropractic office visit. You say that this should be covered. The Plan denied 
your request. The Plan says this is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a chiropractic office visit (99201) provided February 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospice long term care services (code T2046) provided 
from February 1, 2020 to February 17, 2020. 
 
You asked the Plan to pay for the long term care services. You say that when you entered authorization 
information, it stated that authorization was not required for this service. The Plan denied your request. The 
Plan says the denial of payment for these services is correct, because the billed code is not valid for Medicare 
purposes and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code T2046 is not valid for Medicare 
purposes and is not payable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the long term care services have not been met. Therefore, we decided that the Plan does not have to 
pay for the hospice long term care services (code T2046) provided from February 1, 2020 to February 17, 
2020.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for critical services (CPT 99291) provided to the enrollee on January 26, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that several attempts were made to get a corrected claim form, however, one was not submitted. 
 
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 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 services. Our reviewers says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found the review 
has determined that the records supported the coding of CPT 99291. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
critical services (CPT 99291) provided to the enrollee on January 26, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings, periodic oral evaluation, prophylaxis, first 
intraoral periapical x-ray, and additional intraoral periapical x-ray provided on February 12, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the bitewings, periodic oral evaluation, prophylaxis, and intraoral periapical x-
rays. You say that you were not aware that this provider was not an approved dentist at the time of these 
services. The Plan denied your request. The Plan says these services were rendered by an OON provider. The 
Plan also says that authorization was not obtained prior to the services being rendered. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
bitewings, periodic oral evaluation, prophylaxis, first intraoral periapical x-ray, and additional intraoral 
periapical x-ray provided on February 12, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (CPT 88291) provided to the enrollee on 
January 6, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says it has been determined that the claim was denied correctly as a duplicate. 
 
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 88291 is "Cytogenetics and molecular cytogenetics, 
interpretation and report." 
 
We find that CPT code 88291 is not supported in the medical record. Specifically, a claim for these exact same 
services was already paid on January 27, 2020. 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 
pathology services (CPT 88291) provided to the enrollee on January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided to the enrollee on July 30, 2019 and 
billed under code G0482. 
 
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 insufficient medical records were submitted to support the services billed. 
 
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of 
testing. The physicians order and the medical records must specifically show how this testing will be used to 
treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for 
screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we 
decided that the Plan does not have to pay for drug testing provided to the enrollee. Therefore, we decided that 
the Plan does not have to pay for drug testing provided to the enrollee on July 30, 2019 and billed under code 
G0482.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist services rendered on April 7, 
2020. 
 
You asked the Plan to waive the copayment for these services. You say that you disagree with the copayment. 
The Plan denied your request. The Plan says the copayment was applied 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 per visit for specialist services.  
 
Review of the file shows that you received specialist services via telemedicine on April 7, 2020. You have been 
asked to pay a $40 copayment for these services. These services fall within the specialist 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 specialist services rendered on April 7, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $10.36 cost share charged for an office visit and allergy 
shot provided on January 3, 2020. 
 
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan 
denied your request. The Plan says physician/Practitioner services, including doctor's office visits, normally 
have a $20 copayment. The Plan says that since the Medicare allowable amount was less than the applicable 
office visit copayment of $20, you are being asked to pay the lesser amount of $10.36. 
 
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 cost 
share for physician services to provide allergy shots. In this case you are being charged less than the normal 
copayment expectation for this service. 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 $10.36 cost share 
charged for an office visit and allergy shot provided on January 3, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on March 16, 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.  
 
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 psychotherapy services provided on March 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac rehabilitation services (93798) provided on 
September 16, 2019 to September 25, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON cardiac rehabilitation services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says these 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 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 cardiac rehabilitation services (93798) 
provided on September 16, 2019 to September 25, 2019 by an out of network (OON) provider.