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

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 18, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code  billed for date of service March 16, 2022. 
 
You asked the Plan to pay for procedure code . You say that you disagree with the denial. The Plan denied your 
request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64483 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code  have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code  billed for date of service March 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on July 6, 2021. 
 
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 the place of service (POS) on the CMS-1500 form line 24B must reflect the location of 
the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting POS 11.  Also, the laboratory results submitted indicate the 
specimen was collected on July 6, 2021, and received by the lab on July 8, 2021.   
 The Plan also states the enrollee lives in Pennsylvania the billing laboratory is located in Florida, therefore, the 
billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim cannot be paid as billed due to 
an error with the reported POS code. Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on July 6, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 30, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were billed twice and were performed once. 
 
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. 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 these services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on March 18, 
2022. 
 
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 the enrollee did not have prior authorization for out of network care. 
 
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 had network providers available 
who could have provided the services at issue in this appeal.  The Plan did not pre-approve the 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 physician services provided 
to the enrollee on March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from March 31, 2022, to April 
21, 2022. 
 
You asked the Plan to pay for the chiropractic services. You say that you believe the provider is in-network. 
The Plan denied your request. The Plan says the provider of these chiropractic services has not been a contract 
provider since 2021.  Because the provider is out-of-network for this member's specific Plan, the out-of-
network cost sharing applies.  The billed and allowed amounts for each date of service are less than the 
member's out-of-network cost sharing amounts, so no payment is due. 
 
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 $50 copayment per visit for out-of-network chiropractic services.  
 The Plan has confirmed that the provider of service had no active contract with the Plan in 2022. This means 
that the out-of-network cost sharing of $50 per visit applied correctly.  Because the charged amount for each 
date of service is less than this cost sharing obligation, the member is responsible for the full cost of these 
services.  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 pay for chiropractic services provided from March 31, 
2022, to April 21, 2022.  
 
Your complaint about the providers contract status 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Celexa. 
 
You asked the Plan to pre-approve Celexa. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Celexa.  
 
Benefits for Celexa 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder testing (0013M) provided on April 4, 2022. 
 
You asked the Plan to pay for CxBladder testing. You say that this was medically necessary. The Plan denied 
your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that non-coverage has been reaffirmed for codes 
0012M and 0013M for CxBladder.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that 
the Plan does not have to pay for CxBladder testing (0013M) provided on April 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays on May 02, 2022. 
 
You asked the Plan to waive the copayment for x-rays. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing 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 $15 
copayment for Medicare-covered X-rays. Covered services include but are not limited to x-rays.  
 
You have been asked to pay a $15 copayment for x-rays. X-rays fall within the Outpatient diagnostic tests and 
therapeutic services and supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for x-
rays on May 02, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on May 6, 2022. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you cannot afford this copayment, 
and that if you had known it could be charged you would not have had this procedure done. The Plan denied 
your request. The Plan says the copayment that was 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 $275 
copayment for surgery performed in an outpatient hospital setting.  
 
You have been asked to pay a $275 copayment for a colonoscopy. A colonoscopy falls within the Outpatient 
Hospital 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 a colonoscopy 
provided on May 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code  billed for date of service March 24, 2022. 
 
You asked the Plan to pay for procedure code . You say that you disagree with the denial. The Plan denied your 
request. The Plan says the number of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64483 is 1. The MAI value for this code is 2. You billed 4 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code  have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code  billed for date of service March 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman G3R Interspinous device. 
 
You asked the Plan to pre-approve a Minuteman G3R Interspinous device. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 pre-approve a Minuteman G3R Interspinous device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this is an experimental/investigational procedure. The long term 
efficacy and safety of this procedure and device is still under study. Therefore, the request is considered not 
medically reasonable or 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 a Minuteman G3R Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Minuteman G3R Interspinous device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), periapical x-rays 
(D0220, D0230), and bitewing x-rays (D0274) provided on March 28, 2022. 
 You asked the Plan to pay for an evaluation and x-rays. You say that these services are medically necessary 
due to your medical condition. The Plan denied your request. The Plan says that your annual dental maximum 
has been met. 
 
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 have coverage up 
to a $500 annual maximum for covered dental services.   
 
The record shows your annual dental maximum amount has been met. Therefore, you are responsible for any 
amount above the dental maximum amount. An evaluation and x-rays fall within the Dental Service 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 pay for a comprehensive oral evaluation (D0150), periapical x-rays 
(D0220, D0230), and bitewing x-rays (D0274) provided on March 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae gene panel provided to the enrollee on May 3, 
2022. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. The Plan denied 
your request. The Plan says the guidelines for coverage of this panel have not been met. 
 
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 Invitae gene panel 
provided to the enrollee on May 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81162, 81292, 81295, 81298, 81307, 
81317, 81403, 81408, 81479) provided on November 30, 2021. 
 
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan 
denied your request. The Plan says there is not an order for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to be covered, laboratory services must 
be related to a patients illness or injury (or symptom or complaint) and ordered by a physician.  
 
We looked at the file and Medicare rules. The submitted records do not include a physician order for the 
laboratory services at issue. Based on this information, we decided that Medicare rules for coverage of 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory 
services (81162, 81292, 81295, 81298, 81307, 81317, 81403, 81408, 81479) provided on November 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on April 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that these services were medically necessary. The Plan 
denied your request. The Plan says services provided by an out-of-network provider are not covered. 
 
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 physical therapy provided on April 4, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient surgery on March 23, 2022, to 
March 29, 2022. 
 
You asked the Plan to waive the copayments for outpatient surgery. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing 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 $175 
copayment for ambulatory surgical center visits. If you are having surgery in a hospital facility, you should 
check with your provider about whether you will be an inpatient or outpatient. Unless the provider writes an 
order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for 
outpatient surgery. Even if you stay in the hospital overnight, you might still be considered an outpatient. 
There were 2 visits. $175 x 2 = $350. Therefore, results in the total cost sharing amount of $350.  
 
 
 You have been asked to pay a $175 copayment for each 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 copayments for outpatient surgery on March 23, 
2022, to March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
August 4, 2021. 
 
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 the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 out of network physician services provided to the 
enrollee on August 4, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on February 22, 2021. 
 
You asked the Plan to pay for the nursing facility visit. You say that the Plan should have paid secondary on 
this claim. The Plan denied your request. The Plan says the services should be billed under Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a nursing facility visit provided on February 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on February 21, 
2022 and billed under code 77062. 
 
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 code 77062 is assigned a status code I indicated the code is Not valid for Medicare 
purposes. Medicare uses another code for reporting of, and payment for, these services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. In this case, this code is not payable for Medicare 
claims. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee 
on February 21, 2022, and billed under code 77062.