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

 
We decided that the Plan does not have to pay for an office visit (99215) and an electrocardiogram (93000) 
provided on February 17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a preprocedural cardiovascular examination. You say that the medical records 
show that the services were medically necessary. The Plan denied your request. The Plan says the enrollee was 
seen for a pre-operative evaluation for an elective surgery. Therefore, there were no urgent or emergent needs 
at the time of the visit. The Plan also says that there were in-network providers in the enrollees area that could 
have provided these pre-operative services. There was no referral on file nor was there an effort to obtain a 
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 an office visit (99215) and an electrocardiogram 
(93000) provided on February 17, 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 mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that that you need to see this provider who 
exceeds the 50-mile limit. The Plan denied your request. The Plan says you have exceeded your benefit limit. 
 
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 unlimited one-way trips, and each one-way trip must not exceed 50 miles of driving 
distance.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation mileage (A0170).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you have always seen this provider since the 
beginning of your diabetes diagnosis. You say the provider previously accepted your insurance and when it was 
no longer accepted, you changed your doctor. However, you say this provider knows your medical history well. 
The Plan denied your request. The Plan says the rendering provider is no longer in-network. The Plan also says 
there are no referrals from a primary care provider, no evidence of urgent or emergent care, and no pre-
authorization for the services.  
 
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 May 26, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the delivery of complex high precision radiation treatment 
(77386) provided on May 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for radiation treatment. You say that the enrollee meets the criteria for radiation 
treatment and authorization was obtained. You also say the medical records indicate the services were 
medically necessary. The Plan denied your request. The Plan says there is no valid referral on file for the 
services rendered to the enrollee. The services were neither urgent nor emergent and the provider is out-of-
network. The Plan says there is no dispute about the medical necessity of the services, but rather, the lack of a 
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 the delivery of complex high precision radiation 
treatment (77386) provided on May 6, 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 the inpatient hospital services provided 
from May 16, 2022, to May 19, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you did not have a 
private room, were in the hallway, and were not offered any food. The Plan denied your request. The Plan says 
the copayment amount you are being charged 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 a $360 
copayment each day for day(s) 1 to 5, and a $0 copayment for days 6 and beyond for Inpatient hospital care.  
 
 
  You have been asked to pay a $360 copayment each day for day(s) 1 to 5, and a $0 copayment for days 6 and 
beyond for the inpatient hospital services. The inpatient hospital services fall 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 the inpatient hospital services 
provided from May 16, 2022, to May 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided May 27, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you would like this service covered. The 
Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on May 27, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided May 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27216 billed for date of service October 12, 
2021. 
 
You asked the Plan to pay for procedure code 27216. You say that you have provided medical records to 
support payment of this code. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 27216 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 27216 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 27216 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 27216 billed for date of service October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service February 26, 
2022. 
 You asked the Plan to pay for procedure code 99497. You say that you have provided medical records 
supporting payment for this code. The Plan denied your request. The Plan says payment for code 99497 is 
bundled into payment for code 99223. 
 
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 99497 
is a column II code to column I code 99223. 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 99497 billed for date of service February 26, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tele-health service (99442) provided on May 31, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that due to the ongoing crisis 
and low staffing, it is very hard to work in a regular way. You say that it was not possible to get authorization 
before the services were rendered. You also say that it is not a good time to advise patients to look for an in-
network provider. The Plan denied your request. The Plan says prior authorization was not obtained before the 
service was rendered. The Plan says that the enrollee was not referred by a network provider. The Plan also 
says that the services were not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 the tele-health service (99442) provided on May 31, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for intensity modulated radiation treatment delivery (IMRT) provided on 
May 4, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for out-of-network services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says that services from non-participating providers are not covered 
unless they are pre-authorized. 
 
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 Plans contract states that prior authorization is not required for covered services received out-of-
network. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan denied the requested services because prior authorization 
was not obtained. However, the Plans contract clearly states that prior authorization is not required for services 
received out-of-network. The Plan has provided no other reason for denial in this case. Therefore, we decided 
that the Plan has to pay for intensity modulated radiation treatment delivery (IMRT) provided on May 4, 2022, 
by an out-of-network provider.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management injections provided on March 16, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the pain management injections. You say that this facility is in-network and 
should be paid for by the Plan. The Plan denied your request. The Plan says the services were provided out-of-
network and were not approved in advance. 
  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 pain management injections provided on 
March 16, 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 outpatient surgery performed on June 3, 
2022. 
 
You asked the Plan to waive the coinsurance for outpatient surgery. You say that you cannot afford to pay this. 
The Plan denied your request. The Plan says the cost share 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). Your contract with the Plan clearly says that you must pay 50% of 
the Medicare allowed amount for outpatient surgery performed at an out-of-network outpatient hospital facility. 
 
 
 
 
 
 You have been asked to pay $3740.24 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 coinsurance for outpatient surgery performed on June 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) provided on May 2, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 
 
 
 
 
 
 The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99204) provided on May 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 67332 and 67343 billed for date of service 
May 6, 2022. 
 You asked the Plan to pay for procedure codes 67332 and 67343. You say that these codes were denied 
incorrectly. The Plan denied your request. The Plan says payment for codes 67332 and 67343 is bundled into 
payment for codes 67331 and 67332. 
 
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 
67332 and 67343 are column II codes to column I codes 67331 and 67332. 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 codes 67332 and 67343 billed 
for date of service May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient office visit (99214) gonioscopy (separate 
procedure) (92020) scanning computerized ophthalmic diagnostic imaging (92133) ophthalmic ultrasound, 
diagnostic, corneal pachymetry (76514) provided on March 9, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diagnostic office visit. You say that you are requesting reconsideration of 
payment. You were not aware this Plan required a prior authorization for services. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for outpatient office visit (99214) gonioscopy 
(separate procedure) (92020) scanning computerized ophthalmic diagnostic imaging (92133) ophthalmic 
ultrasound, diagnostic, corneal pachymetry (76514) provided on March 9, 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 genetic testing provided on March 24, 2022, billed with 
codes 0031U, 0032U, 0033U, 81225, 81226, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81335, 
81355, and 81479. 
 
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 
March 24, 2022, billed with codes 0031U, 0032U, 0033U, 81225, 81226, 81227, 81230, 81231, 81232, 81291, 
81306, 81328, 81335, 81355, and 81479.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intensity modulated radiation treatment delivery (IMRT) 
(77386) provided on May 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the IMRT. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the claim processed correctly. 
 
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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the 
Plan does not have to pay for the intensity modulated radiation treatment delivery (IMRT) (77386) provided on 
May 3, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 26, 2022. 
 
You asked the Plan to pay for the lab services. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says your primary insurer is responsible for processing this 
claim. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the 
lab that provided this service and directed them to bill your primary insurer. As the secondary insurer, the Plan cannot be held responsible for the lab services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for lab services provided on January 26, 2022.