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

 
We decided that the Plan does not have to pay for laboratory services (80307, 82542, 82570, 84153, G0480) 
provided on May 6, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior 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 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 (80307, 82542, 82570, 84153, 
G0480) provided on May 6, 2021 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 January 4, 2022, to January 24, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are in-network with the Plan and with Medicare. 
You also say that services rendered in your office should be covered and paid for. You also say that you have 
treated the above patient for years and would like to continue to service this patient. The Plan denied your 
request. The Plan says services from non-participating providers are not covered under open access unless 
preauthorized. 
 
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 4, 2022, to 
January 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 the laboratory services (81201, 81295, 81298, 81317, and 
81432) provided on December 15, 2021.  
You asked the Plan to pay for codes 81201, 81295, 81298, 81317, and 81432. 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. In this case, we have confirmed that codes 
81295 and 81298 are column II codes to column I code 81432 with a modifier indicator of 0. The column II 
codes are therefore not payable.  
 
The rules also 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 the claim submitted, Medicare billing criteria have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (81201, 81295, 81298, 81317, and 81432) 
provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist visit provided on August 5, 
2021. 
 
You asked the Plan to waive the deductible for a specialist visit. You say that you should not have to pay this 
deductible as you were unaware that this provider was still out-of-network until August 24, 2021. The Plan 
denied your request. The Plan says the deductible applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $500 
deductible for out-of-network physician/practitioner services.  
 
You have been asked to pay a $208.47 deductible for a specialist visit. A specialist visit falls within the Out-
Of-Network Physician/Practitioner 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 deductible 
for a specialist visit provided on August 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on April 18, 
2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you are on a limited income 
and cannot afford the copayment. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing 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 $65 
copayment for urgently needed care services.  
 
You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the 
Urgently Needed 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 an urgent 
care visit provided on April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) on tooth #19 and core buildup, including 
any pins when required (D2950) on tooth #19 provided on April 5, 2022. 
 
You asked the Plan to pay for the crown and core buildup. You say that the crown on tooth #19 had to be 
replaced. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or services was exhausted on date of service January 7, 2019. 
Therefore, we decided that the Plan does not have to pay for the crown (D2740) on tooth #19 and core buildup, 
including any pins when required (D2950) on tooth #19 provided on April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 25, 2019 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior 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 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 November 25, 2019 by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the hospital observation and related services provided on September 1, 
2021, to September 3, 2021. 
 
You asked the Plan to pay for the hospital observation and related services. You say that the claim was 
submitted correctly. The Plan denied your request. The Plan says that the OCE must be corrected as there is an 
edit error. 
 
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. Review of the file shows that various rules pulled from various Medicare 
sources were provided. Various unclear reasons were given for the denial of this claim. The documentation 
does not include explanation of why each of these claim lines were denied. The Plan states that this is denied 
due to the provider not billing as required by coding regulations but never specifies the reasoning of why all of 
the items on the claim are being denied. The Plan, therefore, did not substantiate their denial. Therefore, we 
decided that the Plan has to pay for the hospital observation and related services provided on September 1, 
2021, to September 3, 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the targeted genomic sequence analysis coded 81455 provided on 
November 7, 2021. 
 
You asked the Plan to pay for the targeted genomic sequence analysis. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says that targeted genomic sequence analysis panel is 
non-covered by Medicare 
 
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 81455 is targeted genomic sequence analysis. 
 
We find that CPT code 81455 is supported in the medical record. Specifically, the Plan states that genetic 
testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical 
management of the patient and will be denied automatically as not medically necessary. The Local Coverage 
Article (LCA) used by the Plan is not valid for the provider's billing state of Pennsylvania. This means that we 
cannot use this LCA to support our decision. No other valid denial rationale was presented by the Plan. 
 
Based on this information, we decided that Medicare rules for coverage of the targeted genomic sequence 
analysis have been met. Therefore, we decided that the Plan has to pay for the targeted genomic sequence 
analysis coded 81455 provided on November 7, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Oxygen Equipment provided from 
February 24, 2022, to May 24, 2022. 
 
You asked the Plan to waive the coinsurance for Oxygen Equipment. You say that you should not have to pay 
this coinsurance because you were not made aware of it before the items were delivered to you. The Plan 
denied your request. The Plan says the coinsurance applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME). The allowed amount of this item per month is $111.05 
resulting in a coinsurance amount of $22.01 ($111.05 x 20% = $22.21). You had this item for 4 months ($22.21 
x 4 = $88.84). 
 
You have been asked to pay a $88.84 coinsurance for Oxygen Equipment. Oxygen Equipment falls within the 
Durable Medical Equipment (DME) and Related 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 coinsurance for Oxygen Equipment provided from February 
24, 2022, to May 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on February 22, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are considered screening. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The 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 
laboratory testing provided on February 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from March 1, 2022, 
through March 4, 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 this medication is not a covered benefit under your 
contractual policy or by Medicare. 
 
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 provided 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 the self-administered drugs 
provided from March 1, 2022, through March 4, 2022.  Benefits for these items 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 23, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were unaware of this 
copayment and therefore should not have to pay it. The Plan denied your request. The Plan says the copayment 
applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for diagnostic radiology services.  
 
You have been asked to pay a $100 copayment for an ultrasound. An ultrasound falls within the Diagnostic 
Radiology Services, Such as Ultrasound, Nuclear Cardiac Imaging, PET, MRI, and CT Scan benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an ultrasound provided on March 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for a diagnostic colonoscopy 
performed on March 21, 2022. 
 
You asked the Plan to waive the deductible and copayment for the colonoscopy. You say that you were 
informed there would be no cost for the procedure. The Plan denied your request. The Plan says the correct 
deductible and copayment were 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 $675 deductible which applies to certain items and services. 
 
Your contract with the Plan also clearly says that you must pay a $295 copayment for a diagnostic colonoscopy 
at an outpatient hospital. 
 
The diagnostic colonoscopy falls within the Outpatient Surgery, Including Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers benefit category. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is $675 deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not been met at the time the colonoscopy was received on 
March 21, 2022.  
 
The file shows that on the date of service you had a total of $609.38 remaining to meet your deductible. Once 
this amount was applied, the $295 copayment was applied to the remaining allowed amount balance. The total 
for the service is $908.38 ($609.38 deductible + $295 copayment = $908.38). This means that you have been 
asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does 
not have to waive the deductible and copayment for a diagnostic colonoscopy performed on March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82310, 82728, 83540, 83550, 83970, 84100) 
provided October 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says these services were not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for lab services (82310, 82728, 83540, 83550, 83970, 84100) provided October 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device was medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81406) provided December 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this code is not covered for cardiovascular screening services. 
 
The Plan must follow Medicare rules. Medicare rules say that only the following codes should be billed for 
Cardiovascular Disease Screening: CPT code 80061 (Lipid panel) which includes CPT codes: 82465 
(Cholesterol, serum or whole blood, total), 83718 (Lipoprotein, direct measurement; high density cholesterol) 
and/or 84478 (Triglycerides). 
 
We looked at the file and Medicare rules. This code is not eligible for coverage as a cardiovascular screening 
test. Based on this information, we decided that Medicare rules for coverage of the lab services have not been 
met. Therefore, we decided that the Plan does not have to pay for lab services (81406) provided December 17, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services (99285) provided on 
September 12, 2021. 
 
You asked the Plan to pay for the emergency room services (99285). 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. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on November 12, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the emergency room services (99285) have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room services 
(99285) provided on September 12, 2021.