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

 
We decided that the Plan does not have to pay for the individual psychotherapy services (90837) provided on 
September 6, 2021 to December 9, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy services. You say that you should not have to be responsible for 
services that you were told would be covered. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 had network providers 
available who could have provided 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 individual psychotherapy services (90837) 
provided on September 6, 2021 to December 9, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 26, 2022. 
 
You asked the Plan to pay for the laboratory 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 as 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. 
 
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 code 81479 only. Therefore, we decided that the Plan does not 
have to pay for the laboratory services provided on January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 28, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 had network providers 
available who could have provided 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 an office visit provided on February 28, 2022 by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services provided to the enrollee on August 10, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that Current Procedural Terminology (CPT) code 01630-AA-P3 (105 Units) remains 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 01630 is "Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, 
sternoclavicular joint, acromioclavicular joint, and shoulder joint; not otherwise specified." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that this procedure was done with a 
regional nerve block. The ultrasound picture shows a completed block and the anesthesia record supports the 
duration of the anesthetic. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
anesthesia services provided to the enrollee on August 10, 2021.  
 
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 pay for a rest home visit provided on January 4, 2022 by an OON 
provider. 
 
You asked the Plan to pay for a rest home visit. You say that the authorization should be on file and should fall 
under the authorization as they rendered the services in good faith. The Plan denied your request. The Plan says 
the out-of-network 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 had network providers 
available who could have provided 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 a rest home visit provided on January 4, 2022 by 
an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient surgery provided on March 9, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient surgery. You say that you were told by the Plan that no 
authorization was needed and would like the claim paid. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 
 
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 had network providers 
available who could have provided 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 outpatient surgery provided on March 9, 2022, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 18, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 18, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on October 5, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the imaging services. You say that you provided the medical records and would 
like the claim reprocessed for payment. The Plan denied your request. The Plan says the rendering and 
referring providers are both OON providers and there was no approved authorization. Also, the service 
rendered was not urgent or emergent. 
 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 had network providers 
available who could have provided 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 imaging services provided on October 5, 2021, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (81291 GZ) provided on August 24, 
2021. 
 
You asked the Plan to pay for code 81291 GZ. 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 as 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. Medicare rules also say that items and services 
that are not medically necessary are not covered. Medicare rules state that items submitted with a GZ modifier 
shall be denied automatically and will not be subject to complex medical review. 
 
We find that CPT code 81291 is not supported in the medical record. Specifically, this service includes the GZ 
modifier, which by definition means that these services do not meet the criteria for Medicare coverage. Based 
on this information, we decided that Medicare rules for coverage of the laboratory service have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory service (81291 GZ) provided on 
August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 11, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 had network providers 
available who could have provided 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 an office visit provided on January 11, 2022 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 8, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 had network providers 
available who could have provided 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 an office visit provided on March 8, 2022 by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital services provided from October 28, 2021, to 
November 4, 2021. 
 
You asked the Plan to pay for the hospital 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
Outpatient diagnostic services furnished to a beneficiary more than 3 days preceding the date of the 
beneficiarys admission to the hospital, by law, are not part of the payment window and must not be bundled on 
the inpatient bill with other outpatient services. The record shows that the services at issue were performed 
outside of the 3-day inpatient window. The services would therefore need to be billed separately from the inpatient claim. Therefore, we decided that the Plan does not have to pay for the hospital services provided 
from October 28, 2021, to November 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70460 billed for date of service February 20, 
2022. 
 You asked the Plan to pay for procedure code 70460. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70460 is bundled into payment for 
code 0042T. 
 
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 70460 
is a column II code to column I code 0042T. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70460 billed for date of service February 20, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye exam and to pay for the 
eye refraction provided on December 22, 2020. 
 
You asked the Plan to waive the copayment for the medical eye exam or pay for the eye refraction. You say 
that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you 
received a medical eye exam and eye refraction on the date of service at issue in this appeal. The Plan says that 
the correct $5 copayment applied to the medical eye exam per your contract with the Plan. The eye refraction is 
not a covered service in this case, leaving you responsible for the $20 amount for the eye refraction. 
 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 Vision care. The rules also say that Medicare does not cover routine vision services. 
 
You have been asked to pay a $5 copayment for the medical eye exam and $20 for the eye refraction. The 
medical eye exam falls within the Vision care 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. Furthermore, eye refraction services are considered routine vision services 
and are not covered under your Medicare vision benefits. Therefore, we decided that the Plan does not have to 
waive the copayment for the medical eye exam and to pay for the eye refraction provided on December 22, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail debridement provided on December 15, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for nail debridement. You say that you are a diabetic and you receive this service 
every 3 months. You say that you did not know an authorization was needed. The Plan denied your request. 
The Plan says no authorization for service is on file. 
 
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 had network providers 
available who could have provided the nail debridement at issue in this appeal. The Plan did not pre-approve 
the nail debridement 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 nail debridement provided on 
December 15, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional 
transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been 
exhausted. Therefore, coverage criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers 24 one-way transportation trips when each one-way trip does not exceed 50 miles 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for computed tomography guidance for placement of radiation therapy 
fields provided to the enrollee from October 4, 2021, to October 6, 2021. 
 
You asked the Plan to pay for the services. You say that this was needed to authenticate the order and 
medically necessity of treatment provided to the enrollee. The Plan denied your request. The Plan says that this 
code is incidental to the main procedure. 
 
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. 77014 is a code that can be reported separately if medically necessary. The plan 
has not stated why this code cannot be reported separately in this case. Their denial is vague and not 
substantiated. Therefore, we decided that the Plan has to pay for computed tomography guidance for placement 
of radiation therapy fields provided to the enrollee from October 4, 2021, to October 6, 2021.  
 
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 comprehensive eye exam (92004) scanning 
computerized ophthalmic diagnostic imaging (92134) determination of refractive state (92015) provided 
January 6, 2022. 
 
You asked the Plan to waive the copayment for the vision services. You say that you feel that the Plan should 
cover for the services. The Plan denied your request. The Plan says this claim was processed correctly per the 
Evidence of Coverage. 
 
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 
copay for level 1 physician services to diagnose and treat diseases and conditions of the eye and $75 copay for 
advanced imaging services.  
You have been asked to pay $115.83 for the vision services. Refraction is not a covered benefit. The vision 
services fall within the Outpatient diagnostic tests and therapeutic services and supplies and Vision care 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 comprehensive eye exam (92004) scanning 
computerized ophthalmic diagnostic imaging (92134) determination of refractive state (92015) provided 
January 6, 2022.