Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on March 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit provided on March 19, 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 the office visits provided on January 6, 2022, February 8, 
2022, and February 24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visits. You say that you have seen this provider prior to the dates of 
service, and you were never told the provider was out-of-network. The Plan denied your request. The Plan says 
the rendering provider is an OON provider and there was no valid authorization. Also, there was no contact 
with the Plan regarding the enrollee's benefits or if the provider was an in-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 the office visits provided on January 6, 2022, 
February 8, 2022, and February 24, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from June 
27, 2021, to July 3, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you cannot afford this bill 
it should be waived. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $225 
copayment per day for days 1through 8.  
 
You have been asked to pay $1,350 ($225 x 6 days) copayment for inpatient hospital stay. Inpatient hospital 
stay falls within the Inpatient Hospital 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 inpatient hospital stay provided from June 27, 2021, to July 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 20, 
2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says as a general rule, the date of service for a clinical laboratory test or the technical 
component of physician pathology service must be the date the specimen was collected. 
 
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 81479 is "Unlisted molecular pathology procedure." 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the date of service is not 
supported. The date of service is for a laboratory services must be date that the specimen was collected, which 
would be December 6, 2021 or December 23, 2021 for this case. 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 laboratory services provided to the enrollee on January 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on February 
16, 2021, and April 13, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that the enrollee is on a limited 
low income. The Plan denied your request. The Plan says the copayment was applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $150 copayment per one-way trip by ground or air ambulance.  
 
The enrollee has been asked to pay $300 ($150 copay x 2 trips) for ambulance services. Ambulance services 
fall within the Ambulance Services benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for ambulance services provided on February 16, 2021, and April 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on March 30, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you were told that any 
diagnosis of breast cancer would waive the copayment for the surgery so you feel it should be waived. The 
Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $350 
copayment per date of service in an outpatient hospital facility.  
 
You have been asked to pay $350 copayment for outpatient surgery. Outpatient surgery 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 copayment for outpatient surgery provided 
on March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dance classes. 
 
You asked the Plan to pay for dance classes. You say that you want the Plan to cover this. The Plan denied 
your request. The Plan says the service at issue is not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The Plans rules for coverage of gym benefits have not been met because dance classes are not a covered 
benefit. Therefore, we decided that the Plan does not have to pay for dance classes.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unattended sleep study provided on April 25, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an unattended sleep study. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says a non-participating provider rendered the services. The 
Plan also says that payment was not allowed because they did not receive a primary care physician referral to 
review and approve. The Plan also says that a non-participating provider referred the member. 
 
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 unattended sleep study provided on April 25, 
2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the Part B drug denosumab provided from 
September 27, 2021, to March 28, 2022. 
 
You asked the Plan to waive the cost share for the injections. You say that this should be covered because you 
need these injections. You say you cannot afford that much for each injection. 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 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay a 20% coinsurance for Part B drugs for a total of $506.28 ($254.52 first injection + 
$251.76 second injection = $506.28). The denosumab injections fall within the Medicare Part B Prescription 
Drugs benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the Part B drug denosumab 
provided from September 27, 2021, to March 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist brace provided on April 11, 2022. 
 
You asked the Plan to pay for the wrist brace. You say that this item should be covered. The Plan denied your 
request. The Plan says the medical records do not support the need for this item. 
 
The Plan must follow Medicare rules. The rules state that if the information in the patients medical record does 
not adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved.  
The record does not contain relevant medical records which support medical necessity for the brace provided in 
this case. Specifically, the medical records provided document no conditions or reasons why this wrist brace 
was ordered or that the patient suffers from any condition at all related to the wrist. Therefore, we decided that 
the Plan does not have to pay for the wrist brace provided on April 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service March 10, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 71045 is bundled into payment for code 74022. 
 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 71045 
is a column II code to column I code 74022. 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 71045 billed for date of service March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye examination (92014) provided on November 8, 2021, 
by an out-of-network provider. 
 
You asked the Plan to pay for an eye examination. You say that the service should be covered. The Plan denied 
your request. The Plan says the services are not covered with an out-of-network provider.  
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 covers these services when the service is rendered with a network provider. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of an eye examination have not been met. Therefore, we decided that the Plan does not have to pay 
for an eye examination (92014) provided on November 8, 2021, by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on July 24, 
2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you are on a fixed income 
and need this to be covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $325 
copayment per trip for Medicare-covered ambulance services.  
 
You have been asked to pay $325 copayment for ambulance transport. Ambulance transport 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 transport 
provided on July 24, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the DermTech melanoma test provided to the enrollee on February 21, 
2022. 
 
You asked the Plan to pay for the test. You say that the laboratory requisition documents the tests ordered, 
along with the results. The Plan denied your request. The Plan says that services should not be experimental or 
still under clinical investigation. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 pay for the test. Our reviewer says that the requested 
services are considered medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has a history of melanoma and basal cell carcinoma. The DermTech Melanoma Test is a non-invasive 
genomic test used to enhance the early detection of melanoma by detecting the presence of genomic markers 
found in melanomaoften times earlier than the current biopsy pathway. Given the enrollee's history of 
melanoma. the review has determined that the items/services at issue in this case were medically reasonable 
and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the test have been met. Therefore, we decided that the Plan has to pay for the 
DermTech melanoma test provided to the enrollee on February 21, 2022.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on March 23, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this would cause a financial 
hardship so it should be covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $325 
copayment per one-way trip for Medicare covered ambulance services.  
 
You have been asked to pay $325 copayment for ambulance transport. Ambulance transport 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 transport 
provided on March 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle brace billed with code L1971-LT-KX 
 
You asked the Plan to pay for the ankle brace. You say that this item should be covered because it meets all 
Medicare requirements. The Plan denied your request. The Plan says you billed with an incorrect 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 L1971-LT-KX is ankle/foot orthosis, plastic or other 
material with ankle joint, prefabricated, includes fitting and adjustment.  The definition of the LT modifier is 
left side. 
 
We find that CPT code L1971-LT-KX is not appropriate based on the medical record. Specifically, you billed 
with the LT modifier indicating that the ankle brace is for the left side.  However, the diagnosis code you billed 
with (M25.571) is specific to pain in the right ankle and joints of the right foot. The diagnosis code and the 
code for the brace itself do not match. Based on this information, we decided that Medicare rules for coverage 
of the ankle brace have not been met. Therefore, we decided that the Plan does not have to pay for the ankle 
brace billed with code L1971-LT-KX
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies provided on March 2, 2022. 
 You asked the Plan to pay for the services provided. You say that the claim was billed in accordance the 
enrollee's plan policy. The Plan denied your request. The Plan says the documentation did not support the billed 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that if the information in the patients medical record 
does not adequately support the medical necessity for the item, the supplier is liable for the dollar amount 
involved. 
 
We looked at the file and Medicare rules. We find that the need for the provided supplies is not supported in 
the medical records. The records in the case file are from 2020. These records do not indicate that the 
equipment was part of the enrollees treatment plan, or that coverage criteria were met. There are no recent 
medical records to justify the need for the equipment. Based on this information, we decided that the Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the electrical 
stimulator supplies provided on March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 8, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the rendering physician is a 
hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain the 
proper authorization from the patient's insurance company. The Plan denied your request. The Plan says 
services from non-participating providers are not covered 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 subsequent nursing facility care provided on 
February 8, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an injection of an eye drug provided on 
April 27, 2022. 
 
You asked the Plan to waive the deductible for an injection of an eye drug. You say that you did not have the 
intravitreal injection of a pharmacologic agent (67028). You also say that you did have an aflibercept injection 
(J0178). The Plan denied your request. The Plan says you were charged the correct cost sharing amount. 
 
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 all items and services except those specifically 
excluded by the Plan contract.  
 
You have been asked to pay $110.08 for an injection of an eye drug. An injection of an eye drug falls within 
the benefit category outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $750 deductible which applies to outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time an injection of an eye drug was received on April 27, 2022. Please note, the record shows 
that an injection of an eye drug was received by the enrollee. Therefore, we decided that the Plan does not have 
to waive the deductible for an injection of an eye drug provided on April 27, 2022.