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

 
We decided that the Plan does not have to pay for the genetic testing provided on June 6, 2022, billed with 
codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81306, 81335, 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that this claim should be covered. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
Additionally, the Plan states that the service with an incorrect place of service. 
 
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 
June 6, 2022, billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81306, 81335, 81355.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from February 23, 2022, to 
June 8, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says this provider type is 
not eligible in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist (MFT) is not 
eligible to participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist 
(MFT). Medicare says that a Marriage Family Therapist (MFT) is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from  
February 23, 2022, to June 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 80299-59 (x3) billed for date of service December 28, 
2021. 
 
You asked the Plan to pay for code 80299-59 (x3). You say that this claim was been underpaid. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. The Plan states that it has already paid for three units of code 80299-59. 
 
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 on March 7, 2022. 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 code 80299-59 (x3) have not been met. Therefore, we decided that the Plan does not have to pay for code 80299-59 (x3) billed for date of service 
December 28, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care and subsequent hospital care 
provided from April 6, 2022, to April 11, 2022. 
 
You asked the Plan to pay for the hospital care. You say that the services should be covered. The Plan denied 
your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before 
rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  
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 the initial hospital care and subsequent hospital care provided 
from April 6, 2022, to April 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service February 22, 
2022. 
 
You asked the Plan to pay for procedure code 74176. You say that this service should be paid. The Plan denied 
your request. The Plan says there is insufficient information to support this service as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure code 74176 have been met. 
Specifically, no medical records were provided to support that this service was medically necessary and 
reported accurately. Therefore, we decided that the Plan does not have to pay for procedure code 74176 billed 
for date of service February 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 25, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
advised to contact emergency medical services when your atrial fibrillation was acting up. The Plan denied 
your request. The Plan says it was confirmed with the treating provider that you refused to be transported. 
 
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 April 25, 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 with no 
transport (A0998) provided on April 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy provided on February 15, 
2022. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged 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 $275 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay $275 copayment for colonoscopy. This item/service 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 colonoscopy provided on February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for echocardiography provided on April 7, 
2022. 
 
You asked the Plan to waive the copayment for echocardiography. You say that you are disputing the share 
cost. The Plan denied your request. The Plan says this cost sharing was charged 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 $170 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay $170 copayment for echocardiography. This item/service falls 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 echocardiography provided on April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on June 24, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most case, care the enrollee receive from an out-of-network 
provider (a provider who is not part of our plan's network) will not be 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 office visit provided on June 24, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic care to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve chiropractic care. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in this chapter). In most case, care the enrollee receive from an out-of-
network provider (a provider who is not part of our plan's network) will not be 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 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 
chiropractic care 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 ultrasound provided on April 11, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for ultrasound. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says care that the enrollee receives from out-of-network providers will not be covered 
unless the care meets one of the three exceptions described in Section 1.2 of this chapter. For information about 
getting out-of-network care when enrollees have a medical emergency or urgent need for care, please see 
Section 3 in this chapter. 
 
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 ultrasound provided on April 11, 2022, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an in-office outpatient procedure provided on May 19, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an in-office outpatient procedure. You say that this should be covered. The Plan 
denied your request. The Plan says there was no preauthorization by a primary care provider (this is different 
than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
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 in-office outpatient procedure provided on May 
19, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a pacemaker check provided on August 1, 
2022. 
 
You asked the Plan to waive the copayment for a pacemaker check. You say that you feel you should not have 
a copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $45 
copayment for prosthetic devices/pacemaker checks.  
 
You have been asked to pay a $45 copayment for a pacemaker check. However, you are only being asked to 
pay is $31.04, which is less than the required amount. This item/service falls within the prosthetic 
devices/pacemaker checks 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 pacemaker 
check provided on August 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiology (ECG) provided on July 
11, 2022. 
 
You asked the Plan to waive the copayment for ECG. You say that You feel that you should pay a$50 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $175 
copayment for outpatient diagnostic tests/Medicare-covered outpatient diagnostic procedure.  
 
You have been asked to pay a $175 copayment for ECG. This item/service falls within the outpatient 
diagnostic tests/Medicare-covered outpatient diagnostic procedure 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 an echocardiology (ECG) provided on July 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray services provided on December 8, 
2021. 
 
You asked the Plan to waive the copayment for x-ray services. You say that you disagree with the copayment. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $45 
copayment for outpatient diagnostic tests/x-ray services.  
 
You have been asked to pay a $45 copayment for x-ray services. This item/service falls within the outpatient 
diagnostic tests/x-ray 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 x-ray 
services provided on December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 0397T billed for date of service January 31, 2022. 
 
You asked the Plan to pay for code 0397T. You say that this code is payable every 30 days. The Plan denied 
your request. The Plan says no records were provided to determine the necessity of the service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of code 0397T have been met. 
Specifically, no medical records have been provided with your appeal, despite multiple requests from the Plan 
for you to provide them.  Without such records, we cannot determine if these services were necessary or billed correctly.. Therefore, we decided that the Plan does not have to pay for code 0397T billed for date of service 
January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on March 01, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most case, care the enrollee receive from an out-of-network 
provider (a provider who is not part of our plan's network) will not be 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 office visit provided on March 01, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided from February 12, 
2022, to February 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you are requesting an authorization 
with payment issued for the services that were provided to the enrollee. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was 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 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 outpatient hospital services provided from 
February 12, 2022, to February 15, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for radiation treatment 
simulation, radiation dose calculation, radiation treatment device, and MRI of the pelvis provided on October 
14, 2021, to October 27, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for radiation treatment simulation, radiation dose 
calculation, radiation treatment device, and MRI of the pelvis. You say that you cannot afford it. The Plan 
denied your request. The Plan says this cost sharing was charged 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 Medicare Part B prescription drugs and $150 copayment for outpatient diagnostic tests and 
therapeutic services and supplies. The allowed amounts of these Medicare Part B drugs total $3,549.88, 
resulting in a total coinsurance amount of $709.98. 
 
You have been asked to pay 20% coinsurance for radiation treatment simulation, radiation dose calculation, 
radiation treatment device, and MRI of the pelvis and $150 copayment for outpatient diagnostic tests and 
therapeutic services and supplies. These items/services fall within the Medicare Part B prescription drugs 
benefit and outpatient diagnostic tests and therapeutic services and supplies categories. 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 and coinsurance for radiation treatment simulation, radiation dose 
calculation, radiation treatment device, and MRI of the pelvis provided on October 14, 2021, to October 27, 
2021.