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

 
We decided that the Plan does not have to waive the copayment for an office visit provided on April 14, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you went for your annual wellness 
visit and your doctor asked if you had any additional concerns. You say your doctor wrote a request slip for a 
carotid Doppler test. The Plan denied your request. The Plan says the cost-share was assessed 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 $10 
copayment for physician/practitioner services, including doctor's office visits.  You have been asked to pay a $10 copayment for an office visit. Office visits fall within the 
physician/practitioner services, including doctor's office visits benefit category. Based on the claim submitted 
by your provider, services were rendered that incurred an office visit copayment as they were services beyond 
the scope of those covered by the wellness exam. 
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an office visit provided on April 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-ray (73562) provided on April 21, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that this service was ordered by the enrollee's physician. 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 knee x-ray (73562) provided on April 21, 
2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on May 31, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing the enrollee is 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $325 copayment pre one-way trip for Medicare-covered ambulance services. Covered ambulance 
services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that 
can provide care if they are furnished to a member whose medical condition is such that other means of 
transportation could endanger the persons health or if authorized by the plan. 
 
 
 
 
 The enrollee has been asked to pay a $325 copayment for ambulance. Ambulance falls 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 on May 31, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 16, 2022 billed with 
codes 81298, 81292, 81295, and 81317. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not billed correctly. 
 
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 
April 16, 2022 billed with codes 81298, 81292, 81295, and 81317.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on April 20, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you want a $40 copayment 
instead of the $375. 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 $375 
copayment for all other services at outpatient hospital. 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. 
 
 
 
 You have been asked to pay a $375 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 on April 20, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150), intraoral - complete series of radiographic images (D0210), 2D oral/facial photographic image 
obtained intra-orally or extra-orally (D0350) and cone beam computed tomography (CT) capture and 
interpretation with field of view of both jaws; with or without cranium (D0367) 
 
You asked the Plan to pay for the dental services. You say that you would not have had these services if you 
had known they would not be covered. The Plan denied your request. The Plan says your benefit for the the 
comprehensive oral exam and complete series of x-rays has already been exhausted. The 2D photographs and 
cone beam CT scan are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the comprehensive oral exam and complete series of x-rays was exhausted on date of 
service April 11, 2022. The 2D oral photographs and cone beam CT scan are not covered under your benefits. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or 
established patient (D0150), intraoral - complete series of radiographic images (D0210), 2D oral/facial 
photographic image obtained intra-orally or extra-orally (D0350) and cone beam computed tomography (CT) 
capture and interpretation with field of view of both jaws; with or without cranium (D0367)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 11, 2022, and billed 
with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81306, and 81335. 
 
You asked the Plan to pay for genetic testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not billed correctly. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on April 11, 
2022, and billed with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81306, and 81335.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 26, 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 are not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on May 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided the Plan does not have to pay for orthopedic socks and orthopedic slippers purchased on April 6, 
2022.  
 
You asked the Plan to pay for these items. You say that these items were medically necessary. The Plan denied 
your request. The Plan says these items were purchased out of network and are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. Orthopedic socks and slippers are preventative in nature. These are self-help devices that may 
be beneficial for your use but are not considered to be medical grade durable medical equipment. These items 
are available to the general public and would be helpful even to those who are not sick or injured. Therefore, 
we decided that the Plan does not have to pay for orthopedic socks and orthopedic slippers purchased on April 
6, 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 
January 20, 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 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 January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on April 21, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing the enrollee is 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $40 copayment for each covered visit or consultation in an outpatient location with a specialist. 
Covered services include consultation, diagnosis, and treatment by a specialist. 
 
The enrollee has been asked to pay a $40 copayment for office visit. Office visits fall within the 
Physician/Practitioner services, including doctor's office visits 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 office visit on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) and the infrared 
therapy (97026) provided on January 3, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by a non-covered 
provider type. 
  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.  
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and the Medicare rules. Based on this information, we decided that the rules for coverage 
of the acupuncture services have not been met. Specifically, the services in this case were performed by an 
acupuncturist who was not under the supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist. Therefore, we decided that the Plan does not have to pay for the 
acupuncture treatment (97810, 97811) and the infrared therapy (97026) provided on January 3, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 25, 2022. 
 
You asked the Plan to pay for the medical services. You say that the patient's hospice election had terminated 
before this date of service. The Plan denied your request. The Plan says Original Medicare is responsible for 
this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on March 19, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for medical services 
provided on March 25, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service January 10, 
2022. 
 
You asked the Plan to pay for procedure code 99284. You say that these are separate services. The Plan denied 
your request. The Plan says payment for code 99284 is bundled into payment for code 29515.  
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 99284 
is a column II code to column I code 29515. 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 99284 billed for date of service January 10, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 69990 billed for date of service March 14, 2022. 
 
You asked the Plan to pay for code 69990. You say that this service was medically necessary and should be 
paid. The Plan denied your request. The Plan says payment for code 69990 is bundled into payment for code 
22600. 
 
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 69990 
is a column II code to column I code 22600 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for code 69990 billed for date of service March 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on April 1, 2022 and 
billed under code 83789. 
 
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan 
denied your request. The Plan says payment for code 83789 is included in the payment for code G0481 and 
cannot be separately reimbursed. The medical records received do not support that the procedure or service was 
distinct or independent from other services performed. This code also is not separately reimbursed when billed 
for specimen validity testing on specimens used for drug testing. 
 
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 code 83789 cannot be paid as billed as it 
is not a separately payable code for these services. 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 April 
1, 2022 and billed under code 83789.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 22, 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 procedure code 81479 is not supported. 
 
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 specimen was not 
collected on the billed date of service. 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 the laboratory 
services rendered on February 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for IV services provided on April 11, 2022. 
 
You asked the Plan to pay for the IV services. You say that the provider coded this bill incorrectly.  You said 
that you needed these IV services due to elevated BUN levels in your blood work. The Plan denied your 
request. The Plan says the provider that you used is not a Medicare-certified provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for IV services provided on April 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided [ENTER DATES 
OF SERVICE]. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the medical records support the 
necessity of this admission. The Plan denied your request. The Plan says the medical records do not support 
that criteria were met for inpatient hospitalization. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the documentation indicates that the enrollee was a 50-year-old female who was 
directly admitted to the hospital from a physician office on March 29, 2021, with plans for an incision and 
drainage of seroma of the left hip. She entered the operating room (OR) at 16:23. Surgery ended at 17:08. She 
was discharged from post-anesthesia care unit (PACU) the same day, March 29, 2021, with discharge 
instructions signed at 18:07. The review indicates that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the patient's necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided [ENTER DATES OF SERVICE].