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

 
We decided that the Plan has to pay for genetic testing provided on March 25, 2020. 
 
You asked the Plan to pay for genetic tests. You say that this testing is covered by Medicare and should be paid 
by the Plan. The Plan denied your request. The Plan says that the denial of payment for these services is 
correct, because prior authorization was not obtained for this testing. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. While the Plan claims that prior authorization is required for these services, the 
Evidence of Coverage (EOC) does not clearly disclose mandatory prior authorization requirements for genetic 
testing. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or 
justified according to Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing 
provided on March 25, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided from February 5, 2020 to 
May 6, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the OON mental health services. You say that you have been seeing this provider 
for many years and want to continue seeing him because he works for you. The Plan denied your request. The 
Plan says only the services of network providers are covered unless prior authorization is obtained. There are 
in-network psychiatrists who can provide this 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 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 mental health services provided from February 
5, 2020 to May 6, 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 fluoroscopic guidance for needle placement (77002) 
provided December 12, 2019. 
 
You asked the Plan to pay for the fluoroscopic guidance for needle placement. You say that please see the 
attached claim, along with information about 64405 where it does not include fluoroscopic guidance as well as 
information showing that 64405-RT and 7702-RT do not bundle. The Plan denied your request. The Plan says 
this service was performed as an inherent part of the nerve block as fluoroscopic guidance was used in order to 
perform the block. The records do not support that there were 2 separate blocks 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, we have confirmed that code 77002 
has a bundled relationship with code 64405 and cannot be paid as billed. This code cannot be paid as a separate 
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided 
that the Plan does not have to pay for the fluoroscopic guidance for needle placement (77002) provided 
December 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture (D0364) provided on June 2, 
2020. 
 
You asked the Plan to pay for the cone beam CT capture (D0364). You say that you had a really bad infection 
and the x-rays were needed. You say that you were informed the dentist accepted your insurance and it was 
covered. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 cone 
beam CT capture (D0364) provided on June 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MTHFR gene analysis provided on February 11, 2020. 
 
You asked the Plan to pay for the MTHFR gene analysis. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that MTHFR gene analysis is only covered for 
enrollees that are pregnant. 
 
We looked at the file and Medicare rules. Review of the file does not support that the enrollee was pregnant. 
Based on this information, we decided that Medicare rules for coverage of the MTHFR gene analysis have not 
been met. Therefore, we decided that the Plan does not have to pay for the MTHFR gene analysis provided on 
February 11, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 15, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you depend upon the hospital staff to verify 
eligibility and to obtain the proper authorization from the member's insurance. The Plan denied your request. 
The Plan says the provider did not make attempts to verify the member's correct insurance, eligibility, or 
authorization requirements prior to rendering non-emergent services. The Plan states there is no evidence of 
plan directed care and the member was not receiving skilled services or inpatient services during this time. The 
Plan states the provider did not provide good cause for why prior authorization was not requested. 
 
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 15, 2020 
by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 27, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that your family found you unconscious and 
called the ambulance. You said that after the medics treated you did not want to go to the hospital. The Plan 
denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 27, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 27, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to hold you harmless for injections (96374, 96375) provided on January 12, 2020. 
 
You asked the Plan to hold you harmless for injections. You say that you should not be billed for these 
services. The Plan denied your request. The Plan says that these services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. The rules also say that while many services and appliances used to treat TMJ fall 
within the Medicare program?s statutory exclusion, treatment for temporomandibular joint (TMJ) syndrome 
may be covered when the actual condition or symptom is medical in nature and the services provided are 
reasonable and necessary for the diagnosis and/or treatment of a medical illness or injury. 
 
The injections at issue were provided by a contract provider. The file does not show that the Plan provided 
notice that an injection would not be covered. Under Medicare rules, this means an injection is considered 
approved by the Plan. Medical records have not been submitted to verify whether these services would fall 
under the Medicare exclusions. Therefore, we decided that the Plan has to hold you harmless for injections 
(96374, 96375) provided on January 12, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 18, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that that you fell and could not get back up. 
You say this is considered an emergency. The Plan denied your request. The Plan says these services are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 18, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided from November 
11, 2019 to November 25, 2019. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you paid in cash. The Plan 
denied your request. The Plan says the copayment you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
copayment for physical therapy provided in an in-network specialist's office.  
 
You have been asked to pay a $15 copayment for three physical therapy visits ($5 x 3). Physical therapy falls 
within the outpatient rehabilitation 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 physical therapy provided from November 11, 2019 to November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiologic examination, foot (73630) 
provided March 5, 2020. 
 
You asked the Plan to waive the copayment for the foot x-ray. You say that the went to see the provider and he 
did not do a good job cutting your toe nails. He rushed and cut your skin. You feel that having a large bill for 
poor service is not right. The Plan denied your request. The Plan says the copayment was applied correctly per 
the plan 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). Your contract with the Plan clearly says that you must pay $20 
copayment for x-rays and ultrasounds.  
 
You have been asked to pay $20 copayment the foot x-ray. The foot x-ray falls within the outpatient diagnostic 
tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for radiologic examination, foot (73630) provided March 5, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 11, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you depend upon the hospital staff to verify 
eligibility and to obtain the proper authorization from the member's insurance. The Plan denied your request. 
The Plan says the provider did not make attempts to verify the member's correct insurance, eligibility, or 
authorization requirements prior to rendering non-emergent services. The Plan states there is no evidence of 
plan directed care and the member was not receiving skilled services or inpatient services during this time. The 
Plan states the provider did not provide good cause for why prior authorization was not requested. 
 
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 December 11, 
2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion services (J7030) provided February 5, 2020 
 
You asked the Plan to pay for the infusion services. You say that the items were medically necessary. The Plan 
denied your request. The Plan says the records do not support the services 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 J7030 is infusion, normal saline solution, 1,000 c. 
 
We find that CPT code J7030 is not supported in the medical record. Specifically, the record does not show that 
the solution was administered on the date of service. Based on this information, we decided that Medicare rules 
for coverage of the infusion services have not been met. Therefore, we decided that the Plan does not have to 
pay for infusion services (J7030) provided February 5, 2020.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room (ER) services rendered on April 23, 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 that procedure code 99283 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that procedure code 99283 is not separately payable because it is 
unbundled to approved code 90935; however, there are no active NCCI edits showing that the codes cannot be 
paid separately when billed together. Therefore, we decided that the Plan has to pay for the emergency room 
(ER) services rendered on April 23, 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 copayment for an office visit provided on June 12, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that you believed there would be no 
charge for the visit. The Plan denied your request. The Plan says the copayment you are being charged is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment per visit with an in-network Primary Care Physician (PCP).  
 
You have been asked to pay a $15 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 June 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete lower denture provided on September 19, 2019. 
 
You asked the Plan to pay for the complete lower denture provided on September 19, 2019. You say that you 
had to see the oral surgeons because of the damage to your jaw, teeth and facial deformity. You say that you 
submitted receipts for reimbursement. The Plan denied your request. The Plan says the requested denture is 
dental in nature and not covered by the medical plan. All other rendered services were approved on appeal. 
 
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 denture is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete 
lower denture provided on September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit provided on February 
18, 2020. 
 
You asked the Plan to waive the copayment for Initial Preventive Medicine New Patient age 40-64 years 
(99386). You say that you should not have a copayment for an annual woman wellness exam. The Plan denied 
your request. The Plan says this was a specialist visit and you were charged the 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 a $40 
copayment for Physician/Practitioner services.  
 
You have been asked to pay a $40 copayment for Initial Preventive Medicine New Patient age 40-64 years 
(99386). Initial Preventive Medicine New Patient age 40-64 years (99386) falls within the 
Physician/Practitioner services benefit category. A Medicare wellness visit covers a Pap smear, pelvic exam, 
and breast exam. The diagnosis codes associated with the claim show a disorder and a colon cancer screening. 
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 visit provided on February 18, 2020.