Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), anti-reflective coating (V2750), 
photochromatic tint (V2744), scratch resistant coating (V2760), and progressive lenses (V2781) provided on 
April 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for frames (V2020), anti-reflective coating (V2750), photochromatic tint (V2744), 
scratch resistant coating (V2760), and progressive lenses (V2781). You say that the optical shop shares office 
space with the provider, who is an approved vendor, you assumed that the optical shop was also in-network. 
The Plan denied your request. The Plan says you must receive your care from a network provider. 
 
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 frames (V2020), anti-reflective coating (V2750), 
photochromatic tint (V2744), scratch resistant coating (V2760), and progressive lenses (V2781) provided on 
April 20, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient surgery services provided 
from February 25, 2022, to February 28, 2022. 
 
You asked the Plan to waive the coinsurance for the outpatient surgery services. You say that you were told 
you would only have a $120 copayment for the surgery. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. Also, the Plan verified the enrollee was never quoted a specific amount on the 
services. 
 
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 20% 
coinsurance for in-network surgery performed at an outpatient hospital facility. The total amount allowed was 
$11,708 with a coinsurance of $2,341.60 ($11,708 total amount x 20% coinsurance). 
 
  You have been asked to pay a $2,341.60 coinsurance for the outpatient surgery services. This item/service falls 
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 the outpatient surgery 
services provided from February 25, 2022, to February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
August 08, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you went to the 
emergency room because they had taken all the stitches out but one. The Plan denied your request. The Plan 
says this cost sharing was charged 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 $50 
copayment for emergency services in an emergency room. 
 
You have been asked to pay a $50 copayment for emergency room services. This item/service falls within the 
emergency services in an emergency room 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 emergency room services provided on August 08, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics (L3020 x 2) provided on June 17, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Additionally, with the exception of the situations described above, orthopedic footwear billed using 
code L3020 will be denied as non-covered. Therefore, we decided that the Plan does not have to pay for the 
foot orthotics (L3020 x 2) provided on June 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging provided on June 20, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for imaging. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says as a member of our plan, the enrollee must use network providers. If the enrollee 
receives unauthorized care from an out-of-network provider, we may deny coverage and the enrollee will be 
responsible for the entire cost. 
 
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 imaging provided on June 20, 2022, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 5, 2022, by an OON 
provider. 
 
You asked the Plan to pay for laboratory services. You say that no authorization is required for the services 
performed. 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 laboratory services provided on May 5, 2022, by 
an OON provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99222) provided on May 14, 2022. 
 
You asked the Plan to pay for the hospital care. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 3, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital care 
(99222) provided on May 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ophthalmological visit provided on July 29, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an ophthalmological visit. You say that you went to this optometrist as your 
previous eye care provider left the practice, please reconsider. The Plan denied your request. The Plan says 
there was no preauthorization by a primary care provider (this is different than a referral) for an out-of-network 
(OON) provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 ophthalmological visit provided on July 29, 
2022, 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. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you have used all 48 one-way trips 
allowed for the 2022 benefit year. 
 
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 a maximum of 48 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. The Plan provided a trip report that does not show you have used all 48 one-way trips for the 2022 benefit year. The trip report only shows that you have 
used 34 of the allotted 48 one-way trips. This means you have 14 one-way trips left for the 2022 benefit year 
and then you will have exhausted this benefit offered by the Plan. The Plan is not approving additional trips. 
Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on December 
11, 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 this was not billed with a valid modifier. 
 
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 A0429 is "Ambulance service, basic life support, 
emergency transport (bls-emergency)." 
 
We find that CPT code A0429 is not supported in the medical record. Specifically, it was billed with modifier 
RW, which is not a valid modifier according to Medicare billing guidelines. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance services provided to the enrollee on December 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PureWick female catheter, provided on March 5, 2022, 
through March 23, 2022. 
 
You asked the Plan to pay for incontinence supplies. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for the PureWick female catheter, 
provided on March 5, 2022, through March 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 28, 
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 June 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 21, 2022 billed with 
codes 81206, 81235, 81292, 81295, 81298, 81317, 81321, 81402, 81162, 81301, 81191, and 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare billing regulations. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 21, 2022 billed with codes 81206, 81235, 81292, 81295, 81298, 81317, 81321, 81402, 81162, 81301, 
81191, and 81309.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 11, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a vascular study on March 28, 2022. 
 
You asked the Plan to waive the copayment for a vascular study. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says this cost sharing was charged 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 $90 
copayment for a vascular study.  
 
You have been asked to pay a $90 copayment for a vascular study. This item/service 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 a vascular study on March 28, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus screening (U0003) provided on December 
23, 2021. 
 
You asked the Plan to pay for the coronavirus screening. You say that the enrollee was not enrolled in hospice 
on the date of service in this case. You also say that this should be reprocessed and paid. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 3, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the coronavirus 
screening (U0003) provided on December 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received from June 2, 2022, to June 
30, 2022. 
 
You asked the Plan to pay for the drugs. You say that you were not able to fill out the Rx claim form that was 
offered to you. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
from June 2, 2022, to June 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on June 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for chiropractic care. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says if the enrollee is choosing to see an Out-Of-Network Provider they will 
need Prior Authorization from the Plan. The enrollees primary care provider (PCP) may have to help the 
enrollee obtain Prior Authorization for the service from WellCare. The services must be medically necessary in 
order to receive 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 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 chiropractic care provided on June 24, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
April 29, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service April 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0428) 
provided on December 22, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says this 
cost sharing was charged 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 $275 
copayment for Ambulance services.  
 
 
  You have been asked to pay a $236.598 copayment for the ambulance transportation services, which is less 
than the standard $275. This item/service falls 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 transportation services (A0428) provided on December 
22, 2021.