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

 
We decided that the Plan does not have to pay for the office visit billed for services provided on June 19, 2019. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the service was 
previously reported and processed. 
 
The Plan must follow Medicare rules. Medicare rules say that claim lines that have been determined to be exact 
duplicates of another claim are denied.  
 
We find that the service at issue was previously billed, with a deductible being applied to the enrollee. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the office visit billed for services provided on June 19, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug panel provided on June 21, 2020. 
 
You asked the Plan to pay for the drug testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says no order showing what drug testing is requested. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the 
treating provider. 
 
The order does not specify which drug classes are to be tested. Therefore, we decided that the Plan does not 
have to pay for the definitive drug panel provided on June 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lymph system imaging (78195) provided on March 18, 2020. 
 
You asked the Plan to pay for the lymph system imaging. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the submitted documentation supports that 
one unit of 78195 was previously approved/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 CPT code 78195 is not supported in the record. Specifically, the record indicates that one unit of 
CPT code 78195 was rendered on this date of service. One unit of CPT code 78195 has already been approved 
and paid. Based on this information, we decided that Medicare rules for coverage of the lymph system imaging 
have not been met. Therefore, we decided that the Plan does not have to pay for lymph system imaging (78195) 
provided on March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on June 3, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that you are appealing this claim. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $65 copayment per visit for out-of-network urgently needed services. You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed 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 urgent care visit provided on June 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services (S9328) provided from 
September 4, 2018 to October 30, 2018. 
 
You asked the Plan to pay for the home infusion therapy services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.  
 
We looked at the file, Medicare rules, and the Plan's rules. Based on this information, we decided that 
Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided 
that the Plan does not have to pay for the home infusion therapy services (S9328) provided from September 4, 
2018 to October 30, 2018.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on January 25, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z code identifier should be adjacent to the code in the 
comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the 
Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on January 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings (D0270) provided on April 23, 2020. 
 
You asked the Plan to pay for the bitewings. You say that this service was necessary. The Plan denied your 
request. The Plan says the frequency limit for this service has been exceeded. 
 
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, bitewings and limited to one procedure 
per plan year. The record shows that you received bitewings (D0274) on January 28, 2020 and your bitewings 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewings (D0270) 
provided on April 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's observation care provided from November 27, 
2019 to November 28, 2019. 
 
You asked the Plan to pay for the physician's observation care. The Plan denied your request. The Plan says the 
contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases 
involving emergency or urgent care, or if the care cannot be provided with an in-network provider, which 
requires prior authorization from 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 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 physician's observation care provided from November 27, 2019 
to November 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telemedicine visit provided by a 
participating provider on March 17, 2020. 
 
You asked the Plan to waive the copayment for a specialist telemedicine visit. You say that you did not have a 
visit due to COVID-19. The Plan denied your request. The Plan says the correct copayment has been 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 $40 
copayment for outpatient diagnostic tests/Select.  
 
You have been asked to pay a $40 copayment for a specialist telemedicine visit. Since specialist services were 
provided over the phone, the correct copayment has been applied. A specialist telemedicine visit falls within 
the outpatient diagnostic tests/Select 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 
specialist telemedicine visit provided by a participating provider on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services rendered on August 20, 2019. 
 
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 when performed by a chiropractor. 
 
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. The file shows that the 
provider submitted a claim for procedure codes 72040 (cervical spine x-ray), 72100 (lumbosacral spine x-ray), 
and 99202 (office visit). Therefore, we decided that the Plan does not have to pay for the chiropractic services 
rendered on August 20, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from January 27, 2020, to January 30, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for the 
services are included in payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Payment for all fees related to this service would have been included under the facility claim. 
Therefore, we decided that the Plan does not have to pay for the services provided from January 27, 2020, to 
January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, first intraoral periapical x-ray, bone 
replacement graft for ridge preservation, and guided tissue regeneration provided on April 2, 2020 and April 3, 
2020 by an OON provider. 
 
You asked the Plan to pay for the extraction, intraoral periapical x-ray, bone replacement graft, and guided 
tissue regeneration. You say that this was an emergency situation. The Plan denied your request. The Plan says 
these services were rendered by an OON provider. The Plan also says that services performed by an OON 
provider 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, you are responsible for paying 100% 
of the cost for services received by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the extraction, first intraoral periapical x-ray, bone replacement graft for ridge preservation, and guided 
tissue regeneration provided on April 2, 2020 and April 3, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the power wheelchair (K0848) provided by 
the out of network (OON) provider on April 7, 2020. 
 
You asked the Plan to issue reimbursement for the power wheelchair. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the wheelchair 
was provided 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 issue reimbursement 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 item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no 
exception that would require the Plan to issue reimbursement for this item. Therefore, we decided that the Plan 
does not have to issue reimbursement for the power wheelchair (K0848) provided by the out of network (OON) 
provider on April 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on September 19, 2019. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration because this service 
was denied as a duplicate in error. The Plan denied your request. The Plan says this service is a duplicate of a 
charge considered on a previous claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claim lines that have been determined to be exact 
duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. The record indicates that CPT code 99213 was previously billed 
and paid on a claim with the same provider, enrollee and date of service. Therefore, we decided that the Plan 
does not have to pay for an office visit (99213) provided on September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services (74248) provided on January 
14, 2020. 
 
You asked the Plan to pay for the diagnostic radiology. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says payment for this service is not allowed 
when billed without an appropriate primary procedure code. 
 
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, we have confirmed that code the 
diagnostic radiology is an add-on code and cannot be paid as billed. Payment for this service is not allowed 
when billed without an appropriate primary procedure code. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic radiology 
services (74248) provided on January 14, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided on 
February 26, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was provided by an out of network 
provider, without prior authorization. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The service at issue in this appeal was not provided in an emergency or urgent care situation. This service was 
not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have 
to pay for the psychiatric diagnostic evaluation (90791) provided on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on September 5, 
2019. 
 
You asked the Plan to pay for the domiciliary, rest home visit. 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 a domiciliary, rest home visit provided on September 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Electroencephalogram (95816) provided on December 
12, 2019. 
 
You asked the Plan to pay for the Electroencephalogram. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were not pre-authorized or emergent. There were 
network providers 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 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 the Electroencephalogram (95816) provided on December 12, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided to the enrollee from 
October 1, 2019 through October 11, 2019. 
 
You asked the Plan to waive the copayment for SNF care. You say that you were not advised of the $100 per 
day cost-share for days 21-100 and the copayment would be a financial hardship. The Plan denied your request. 
The Plan says the claim was processed accordingly with the member's 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 show that the enrollee received SNF care from October 1, 2019 through October 11, 2019. 
The enrollee is asked to pay a $100 copayment for days 21-100 for SNF care. This means that the enrollee has 
been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for SNF care provided to the enrollee from October 1, 2019 through October 11, 
2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from April 2, 2020 to 
April 3, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that these prescriptions were provided to 
you after you had surgery. The Plan denied your request. The Plan says self-administered drugs are not covered 
by Part A or Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from April 2, 2020 to April 3, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided by a participating 
provider on January 2, 2020 to January 16, 2020. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you do not feel like you should 
pay for these copayments. The Plan denied your request. The Plan says the correct copayments have been 
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 $300 
copayment for outpatient surgery.  
 
You have been asked to pay a $300 copayment for cataract surgery. cataract surgery 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 cataract surgery provided 
by a participating provider on January 2, 2020 to January 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided 
on February 15, 2020. 
 
You asked the Plan to pay for the CGP testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the CGP testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the Comprehensive Genomic Profile (CGP) testing provided on February 15, 2020.