Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient mental health services (96116) 
provided January 30, 2020. 
 
You asked the Plan to waive the coinsurance for the outpatient mental health services. You say that the 
coinsurance should be waived. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 40% 
coinsurance for out-of-network outpatient services.  
 
You have been asked to pay a 40% coinsurance for the outpatient mental health services. The outpatient mental 
health services fall within the out-of-network outpatient 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 coinsurance for outpatient mental health services (96116) provided January 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on March 25, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says CPT code 71045 was billed by another physician 
therefore, a corrected claim is required with a 77 modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 71045-26 is not supported in the record. Specifically, the record indicates that CPT 
code 71045 has already been approved and paid for the billed date of service. This claim does not include the 
required modifier to report a repeat procedure by another physician.  Based on this information, we decided 
that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does 
not have to pay for the chest x-ray (71045) provided on March 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from February 8, 2020 through February 15, 2020.
You asked the Plan to pay for inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the enrollee exhausted their benefit.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. The enrollee had been readmitted to the hospital. The enrollee has used up Medicare hospital benefit. The enrollee has already been in the hospital for 120 days without a 60-day break. The enrollee has also used up the lifetime hospital benefit of 60 days. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from February 8, 2020 through February 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on October 1, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a 
physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the drug testing rendered on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a biopsy provided by an out-of-network 
provider on March 18, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with this 
copayment because the provider is out-of-network. 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 $295 
copayment for outpatient surgery/outpatient hospital facility visit.  
 
You have been asked to pay a $295 copayment for an outpatient surgery. In-network and out-of-network 
outpatient surgeries have the same copayment amount; therefore, the correct copayment has been applied. An 
outpatient surgery falls within the outpatient surgery/outpatient hospital facility visit 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 biopsy provided by an out-of-network provider on March 
18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the facet injection rendered on September 4, 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 procedure code 64636 is not supported. 
 
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 64636 is destruction by neurolytic agent, paravertebral 
facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint 
(List separately in addition to code for primary procedure). 
 
We find that CPT code 64636 is not supported in the medical record. Specifically, the operative report does not 
include documentation of a paravertebral facet joint injection with imaging guidance for each additional lumbar 
or facet joint. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the facet injection rendered on 
September 4, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on October 24, 2019. 
 
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory 
requisition form. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the documentation submitted does not include a valid physician order, lab requisition, or 
medical records to support the codes billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan 
does not have to pay for drug testing provided on October 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular PCR urine laboratory testing provided on November 12, 2019.
You asked the Plan to pay for the molecular PCR urine laboratory testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The molecular PCR urine laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the molecular PCR urine laboratory testing provided on November 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided on August 18, 2019.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because this claim
was denied as a duplicate in error. The Plan denied your request. The Plan says the submitted documentation
supports one unit of 71045-26, which 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 71045 is not supported in the record. Specifically, the documentation submitted
supports one unit of CPT code 71045 was rendered on the billed date of service. The record also shows that one
unit of 71045 has previously been approved/paid to this provider. Based on this information, we decided that
Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not
have to pay for a chest x-ray (71045) provided on August 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Meningococcal vaccine provided on April 8, 2020. 
 
You asked the Plan to pay for vaccines under Medicare Part B. You say that the Plan should cover this vaccine. 
The Plan denied your request. The Plan says coverage for this vaccine must be submitted to your Medicare Part 
D carrier. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide vaccines under 
Medicare Part B. The Plan follows the same rules. The records do not show that you have been injured or 
directly exposed to any illness related to vaccines under Medicare Part B. Therefore, we decided that the Plan 
does not have to pay for the Meningococcal vaccine provided on April 8, 2020.  
 
Benefits for vaccines 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on January 2, 2020 by an OON provider.
You asked the Plan to pay for the resin-based composite. The Plan denied your request. The Plan says the service was rendered by an OON dentist. The Plan also says that services done by an OON dentist 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, 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 resin-based composite provided on January 2, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the venipuncture rendered on January 20, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the billed ICD-10 diagnosis code is not billable in 
the primary position. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the venipuncture rendered on 
January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided out of network from March 9, 
2020 to April 10, 2020. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. In a 
letter to the Plan and also a letter to this office, you explained why these services were necessary.  The Plan 
denied your request. The Plan says your primary care physician referred you to a provider in network, however 
you chose to use an out of network provider.  
 
The rules say a plan can require enrollees to use network providers and can also require prior authorization. 
The provider in question is not a Plan contract provider. The Plan has providers in network who can render 
these services if they are medically necessary. It should also be noted that Medicare does not cover 
maintenance chiropractic services for chronic conditions. You did not have prior authorization for out of 
network care. You did not follow your Plans contract rules when you obtained these services. Therefore, we 
decided that the Plan does not have to pay for chiropractic services provided out of network from March 9, 
2020 to April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 3, 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 Plan says this is an administrative determination for coding and is not based on
clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use
of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field.
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 claim is missing the main code
and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of
this claim have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing
provided to the enrollee on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on 
February 11, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you paid the $45 
copayment and were not informed that you would owe additional charges for the injection. 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 20% 
coinsurance for a Medicare Part B prescription drugs.  
 
You had a Medicare Part B drug on February 11, 2020. The allowed amount is $1,027.07 and 20% of that is 
$205.41.  
 
You have been asked to pay the total coinsurance amount of $205.41 for a Medicare Part B drug. A Medicare 
Part B drug falls within the Medicare Part B prescription drugs 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 a Medicare Part B drug provided on February 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory testing provided on April 13, 
2020. 
 
You asked the Plan to waive the copayment for lab test. You say that this was the wrong blood test, so you 
should not have to pay a copayment. The Plan denied your request. The Plan says the copayment amount 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 $10 
copayment for lab test.  
 
You have been asked to pay $10 copayment for lab test. Lab test 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 laboratory testing provided on April 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 10, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for laboratory tests. You say that you are appealing with medical records. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because this provider is 
out-of-network with the Plan and authorization was not obtained. 
 
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 10, 
2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the services (CPT 86765) provided on May 6, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is a duplicate 
of a charge considered on a previous claim. 
 
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 documentation submitted does not show that the services in question were 
billed as a duplicate to services previously paid by the Plan on a separate claim. Without supporting 
documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the 
services (CPT 86765) provided on May 6, 2019.  
 
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: 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 December 19, 2019. 
 
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 December 19, 2019.
Appeal type: Drugs
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 provider. 
 
You asked the Plan to pay for the services. You say that the Plan should pay the claim. 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 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 provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 18, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the office visit (99214). You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says prior authorization was not obtained by the 
provider or facility. 
 
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 March 18, 2020 
by an out of network (OON) provider.