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

 
We decided that the Plan does not have to pre-approve the INR testing to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the INR testing. You say that you would rather the provider come to you 
and give the results instantly versus going to the provider and waiting for the results. The Plan denied your 
request. The Plan says the provider is out-of-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. The record shows you have an in-network cardiologist who has 
been checking INR levels and can continue to do so. Therefore, we decided that the Plan does not have to pre-
approve the mobile INR testing to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided to the enrollee on May 6, 2021 and billed 
under code 43239. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan 
says Medicare billing criteria are not met. 
 
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 asked our coder to look at the case file and the medical records. Our 
coder says that the Plan received a claim for code 43239 for the description of Esophagogastroduodenoscopy, flexible, 
transoral, with biopsy, single or multiple.  The documentation submitted was reviewed and does not meet the required 
criteria. The procedure report does not support modifier 59 (Distinct Procedural Service). Modifier 59 should be used to 
distinguish a different session or patient encounter, different procedure or surgery, different anatomical site or separate 
injury.  Documentation does not support the criteria for modifier 59, and therefore would not be covered. 
Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we 
decided that the Plan does not have to pay for testing services provided to the enrollee on May 6, 2021 and billed under 
code 43239.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from May 19, 2021, to May 22, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you cannot afford 
this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment per day for days 1-5 for inpatient hospital services.  
 
Records show that you were in the hospital for three days.  You were charged a $275 copayment per day, for a 
total of $825.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 services you received 
from May 19, 2021, to May 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit and injection to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the office visit and injection. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the provider is out-of-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office visit and injection to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 test provided to the enrollee on  
June 17, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this test should be reported with CPT 81479. 
 
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 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the Guardant360 test provided to the enrollee on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation and testing provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the consultation and testing. You say that you want to discuss the results of your 
physical therapy to see if it has improved your condition. The Plan denied your request. The Plan says the 
provider is out-of-network. 
 
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 consultation and testing provided by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the frames purchased on May 6, 2021. 
 
You asked the Plan to pay more for the frames. You say that you were charged $194 instead of a $10 
copayment. The Plan denied your request. The Plan says you pay any amount over the benefit maximum of 
$125. 
 
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 up to $125 every year for eyewear. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the frames have not been met. Specifically, the Plan paid $125 out of the total cost of the frames 
leaving you a responsibility of $194. Therefore, we decided that the Plan does not have to pay more for the 
frames purchased on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the Axumin you received on February 2, 
2021, and the radiation therapy services you received on February 19, 2021, and February 22, 2021. 
 
You asked the Plan to waive the cost sharing for the Axumin and the radiation therapy services. You say that 
you paid the $125 copayment for the positron emission tomography (PET) scan, which is the proper 
copayment.  You said that the provider billed separately for the Axumin used in this test.  You stated that this 
imaging agent should be considered part of the test itself. The Plan denied your request. The Plan says you 
were charged these cost sharing amounts 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 $60 copayment for radiation therapy services and 20% coinsurance for Medical supplies.  
 
You have been asked to pay a $60 copayment for the radiation therapy services and 20% coinsurance for the 
Axumin.  You had two separate radiation therapy services on February 19, 2021, and February 22, 2021, so 
these copayments applied correctly. In addition, the contract says that supplies for which an appropriate 
separate charge is made by providers (such as chemical agents used in diagnostic procedures) are subject to 
separate cost sharing.  In other words, the Plan is allowed to charge you separate coinsurance for the Axumin 
supply used during your PET scan. Your contract says that medical supplies are subject to 20% coinsurance. 
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 sharing for the Axumin you received on February 2, 2021, and the 
radiation therapy services you received on February 19, 2021, and February 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown provided on April 28, 2021. 
 
You asked the Plan to pay for the crown. You say that you want to know what the dental program covers if not 
charges for crowns and other procedures over the charges for oral cleanings. The Plan denied your request. The 
Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
provided on April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the biopsy procedure you had at an 
outpatient hospital facility on May 24, 2021. 
 
You asked the Plan to waive the coinsurance for the biopsy procedure. You say that you met your out-of-
pocket maximum, so you should not have to pay this cost sharing. The Plan denied your request. The Plan says 
you were charged this cost sharing correctly. The Plan says that you had not yet met your out-of-pocket 
maximum at the time the claims for this date of service processed. The Plan also stated that with the processing 
of the claim for this service, you have now met your out-of-pocket maximum. 
 
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 20% 
coinsurance for outpatient surgery.  
 You have been asked to pay 20% coinsurance for the biopsy procedure. the biopsy procedure falls within the 
outpatient surgery 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 biopsy 
procedure you had at an outpatient hospital facility on May 24, 2021.  
 
Your complaint about the Plan?s classification of your insulin is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided to the enrollee on March 9, 2020 and billed 
under codes 14301 and 14302. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met. 
 
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 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 
these services. Our reviewer says that Medicare billing criteria are not met. Our reviewer found documentation 
submitted was reviewed. The operative report does not include enough detail to confirm CPT 14301 and CPT 
14302, including measurements of incisions performed to create tissue flap for transfer, as well as, healthy skin 
flap transferred from donor site to adjacent tissue.  Operative report describes undermining, which would not 
be reported with CPT 14301 or CPT 14302. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for services provided to the enrollee on March 9, 2020 and billed under codes 14301 and 14302.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you are handicap and cannot stand in the 
shower. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure 
(CPAP) machine you rented on June 12, 2021. 
 
You asked the Plan to waive the coinsurance for the CPAP machine. You say that you haven't been able to use 
this machine because it causes breathing problems and it was recalled. The Plan denied your request. The Plan 
says you were charged this coinsurance 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the CPAP machine. The CPAP machine falls within the 
durable medical equipment benefit category. This coinsurance applies as long as you have this machine in your possession, regardless of whether or not you are actually using the machine. 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 continuous positive airway pressure (CPAP) machine you rented on June 12, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on September 18, 2020 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for lab tests. You say that there was not an in-network laboratory or alternative that 
could offer the appropriate service needed for the enrollee. The Plan denied your request. The Plan says the 
denial of payment for this testing is correct, because this provider is out-of-network with the Plan and 
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 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 testing provided on September 18, 2020 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the member would benefit from custom 
orthotics with toe fillers to prevent further recurrence of painful chronic lesions. The Plan denied your request. 
The Plan says this item is not a covered benefit. 
 
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. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on May 27, 2021. 
 
You asked the Plan to pay for foot orthotics. You say that you have had surgeries on both feet to correct your 
metatarsal bones and have large toe implants on both feet. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
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. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on May 27, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you 
received from January 19, 2021, to March 5, 2021. 
 
You asked the Plan to waive the copayment for the SNF services. You say that the facility told you they would 
write off this amount.  You stated that the facility gave you incorrect information. The Plan denied your 
request. The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 
copayment for days 1-20. and a $178 copayment per day for days 21-100 for skilled nursing facility services.  
 
Records show that you were in the SNF for 45 days.  You were not charged a copayment for the first 20 days.  You have been charged a $178 copayment per day for remaining 25 days.  This totals $4450, but due to the 
Plan's contracted rates wtih this provider, you are only responsible for $4341.70. 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 skilled nursing facility (SNF) services you received from January 19, 2021, to 
March 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 30. 
 
You asked the Plan to pre-approve the dental service. You say that the service is necessary. The Plan denied 
your request. The Plan says core build up is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested core build up is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
build up (D2950) for tooth # 30.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent observation care (99226) provided on March 13, 
2021. 
 
You asked the Plan to pay for observation care. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because this physician 
was not the admitting physician and therefore must bill the appropriate outpatient service code instead of a 
subsequent observation care code. 
 
The Plan must follow Medicare rules. Medicare rules say that all physicians other than the admitting physician 
must bill the appropriate outpatient service codes for services rendered during outpatient observation.  
 
We looked at the file and Medicare rules. This physician was not the admitting physician for this observation 
stay; therefore, it is not appropriate to bill a subsequent observation care code instead of the outpatient service code for this service. Based on this information, we decided that Medicare rules for coverage of observation 
care have not been met. Therefore, we decided that the Plan does not have to pay for subsequent observation 
care (99226) provided on March 13, 2021.