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

We decided that the Plan does not have to pay for the electroencephalogram (EEG) rendered on February 11, 
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 enrollee was on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the electroencephalogram (EEG) rendered on February 11, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a refraction (92015) provided on July 20, 2020. 
 
You asked the Plan to pay for a refraction. You say that this is included in the exam. The Plan denied your 
request. The Plan says this is not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan one routine eye exam every calendar year performed at any participating network provider 
location. 
 
We looked at the file and the Plan's rules. The refraction at issue was not provided by the Plan's routine vision 
provider network. Based on this information, we decided that the Plan's rules for coverage of a refraction have 
not been met. Therefore, we decided that the Plan does not have to pay for a refraction (92015) provided on 
July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 7, 2020 by a non-
participating provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by a non-participating provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on January 7, 2020 
by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 16, 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 claims were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation rendered on January 7, 2020 to 
February 4, 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 procedure code 97042 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 97032 is application of a modality to 1 or more areas; 
electrical stimulation (manual), each 15 minutes. 
 
We find that CPT code 97032 is not supported in the medical record. Specifically, there is no documentation of 
time spent on electrical stimulation to support billing of this code. 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 electrical stimulation rendered on January 7, 2020 to February 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray coded 74250 provided on June 20, 2020. 
 
You asked the Plan to pay for the x-ray. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the services billed are not separately payable. 
 
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 74250 
for the x-ray has a bundled relationship with code 74246 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 x-ray coded 74250 provided on June 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services (73600, 73630) provided on July 27, 
2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the radiology services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 radiology services (73600, 73630) provided on 
July 27, 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 neuromonitoring services provided to the enrollee on April 1, 
2019. 
 
You asked the Plan to pay for the services. You say that the claim was initially submitted in time. The Plan 
denied your request. The Plan says the claim was not received until April 13, 2020. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until April 13, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for neuromonitoring services provided to the enrollee on April 1, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on June 9, 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 NGS panels must be billed with code 81479. 
 
We looked at the file and Medicare rules. The file shows that the testing was not billed with the required single 
code of 81479. 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 Guardant360 panel rendered on 
June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an outpatient surgery provided by a 
participating provider on June 17, 2020. 
 
You asked the Plan to waive the deductible for an outpatient surgery. You say that you think that this should 
have been covered with the surgery copayment. The Plan denied your request. The Plan says the correct 
deductible amount has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible for outpatient surgery.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
surgery. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible for outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time 
an outpatient surgery was received on June 17, 2020. The total amount you are being asked to pay is $285.97. 
Therefore, we decided that the Plan does not have to waive the deductible for an outpatient surgery provided by 
a participating provider on June 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on June 19, 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 NGS panels must be billed with procedure code 
81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on June 19, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the freestanding emergency room (ER) services rendered on 
May 1, 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 services re not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers services in freestanding emergency 
departments only if the emergency clinic is affiliated with a hospital.  
 
We looked at the file and Medicare rules. The freestanding ER services were not affiliated with a hospital. 
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 freestanding emergency room (ER) services 
rendered on May 1, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Darzalex 100 mg/5 ml solution (J9145). 
 
You asked the Plan to pre-approve Darzalex. You say that Darzalex is medically reasonable and necessary to 
treat your condition. The Plan denied your request. The Plan says that Darzalex is not approved for use with the 
diagnosis received from the doctor. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 pre-approve Darzalex. Our reviewer says that it is 
reasonable and indicated to use this drug on experimental basis. Our physician reviewer found the studies 
available for review show that Darzalex has been shown in case studies to treat nephrotic syndrome. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Darzalex have been met. Therefore, we decided that the Plan has to pre-approve 
Darzalex 100 mg/5 ml solution (J9145).  
 
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 waive the copayment for the ophthalmic ultrasound, diagnostic; 
corneal pachymetry, unilateral or bilateral (76514) provided August 11, 2020. 
 
You asked the Plan to waive the copayment for the radiology services. You say that you feel that you should 
only have to pay the $30 office visit copayment. You do not like being billed. If they are going to charge you 
for something, you should be billed up front. The Plan denied your request. The Plan says this claim was 
processed and 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 $30 
copayment for each Medicare covered x-ray. If an x-ray services are performed in the provider's office during 
an office visit, the appropriate office visit copayment and x-ray copayment will apply.  
 
You have been asked to pay $8.79 for the radiology services. The radiology services fall 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 the ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (76514) 
provided August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a non-
participating provider on May 18, 2020. 
 
You asked the Plan to waive the copayment for specialist telehealth services. You say that these were telehealth 
services. You say that you do not think you should have to pay for that. 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 $25 
copayment for physician/practitioner services/out-of-network/specialist.  
 
You have been asked to pay a $25 copayment for specialist telehealth services. Specialist telehealth services 
fall within the physician/practitioner services/out-of-network/specialist 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 specialist services provided by a non-participating provider on May 
18, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 25, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that the ambulance trip was 
related to COVID-19 and you were informed that you would not owe a copayment. The Plan denied your 
request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for ambulance services.  
 
You have been asked to pay a $225 copayment for ambulance services. Ambulance services fall within the 
ambulance 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 ambulance services 
provided on March 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on May 20, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the member's primary care physician did not refer these services. 
 
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 lab work provided on May 20, 2020 by an out of 
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core provided on July 2, 2020. 
 
You asked the Plan to pay for the prefabricated post and core. You say that your tooth broke off down to the 
gum line. You say that the post core should be included under the restorative services. 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 
prefabricated post and core provided on July 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lens upgrades (V2200, V2784) provided on June 11, 2020. 
 
You asked the Plan to pay for lens upgrades. You say that this should be covered. The Plan denied your 
request. The Plan says upgrades are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers only one pair of conventional 
eyeglasses or contact lenses furnished after each cataract surgery.  
 
The services you asked the Plan to pay for are upgrades to conventional eyeglasses and are not covered. 
 
 
Therefore, we decided that the Plan does not have to pay for lens upgrades (V2200, V2784) provided on June 
11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visits (99214) individual psychotherapy, 
45 minutes (90834) group psychotherapy services (90853) provided January 2, 2020 to January 9, 2020. 
 
You asked the Plan to pay for the outpatient psychotherapy services. You say that the records provided should 
support the necessity of the service in dispute. The Plan denied your request. The Plan says the claim was billed 
without the provider of service, supplier's billing name, address, zip code and telephone number which is 
required 
 
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 was billed without the provider of service, supplier's billing name, address, zip code and 
telephone number which is required. A corrected claim with the rendering/servicing provider details on the 
claim form must be submitted. Based on this information, we decided that Medicare rules for coverage of the 
outpatient psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay 
for the outpatient office visits (99214) individual psychotherapy, 45 minutes (90834) group psychotherapy 
services (90853) provided January 2, 2020 to January 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on January 8, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you are an independent lab. You say that these tests were 
requested. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the member's primary care physician did not refer these services. 
 
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 lab work provided on January 8, 2020 by an out of 
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you received on August 6, 
2020 
 
You asked the Plan to waive the copayment for the lab services. You say that you believe these tests should be 
covered in full. The Plan denied your request. The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for lab services.  
 
You have been asked to pay a $10 copayment for the lab 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 lab services you received on August 6, 2020