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

 
We decided that the Plan does not have to pre-approve a Precision GU Prostate Germline Panel. 
 
You asked the Plan to pre-approve a Precision GU Prostate Germline Panel. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the submission of claims using individual gene CPT 
codes, when either 5-50 or >50 gene panels are ordered, is considered incorrect coding. 
 
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 Precision GU Prostate Germline 
Panel. Our reviewer says that the services are not medically necessary. Our physician reviewer found providers 
should take reasonable measures to be aware of what if any germline testing a beneficiary has had prior to 
billing for germline testing so as to avoid billing Medicare for services that are not reasonable and necessary. 
Clinicians who order germline testing may wish to be aware of whether the test that they are ordering is 
covered under Medicare and may wish to verify that they are not ordering repeat germline testing. The review 
has determined that the enrollee does not meet the coverage criteria detailed in the LCA.  
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 Precision GU Prostate Germline Panel have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Precision GU Prostate Germline Panel.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing care services provided on April 12, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the nursing care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says a referral/authorization was not obtained prior to 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 nursing care services provided on April 12, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
January 3, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service January 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service June 28, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service June 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intermittent limb compression devices (E0651, E0667). 
 
You asked the Plan to pre-approve intermittent limb compression devices. You say that the requested items are 
a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for 
pneumatic devices have not been met. 
 The Plan follows Medicare rules. The rules state that PCD coded as E0650 or E0651 used to treat edema from 
causes other than lymphedema is not eligible for reimbursement. 
 
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 intermittent limb compression devices. 
Our reviewer says that the requested items are not medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not carry a diagnosis of lymphedema. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intermittent limb compression devices have not been met. Therefore, we 
decided that the Plan does not have to pre-approve intermittent limb compression devices (E0651, E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for opioid treatment services provided from 
January 8, 2022, to July 16, 2022. 
 
You asked the Plan to waive the copayments for the opioid treatment services. You say that you feel you are 
being charged twice. 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 $40 
copayment for opioid treatment program services.  
 
The file shows that you had a total of 50 visits for opioid treatment services from January 8, 2022, to July 16, 
2022. You have been asked to pay a $40 copayment for each methadone weekly bundle. 30 of these visits were 
for this service, for a total of $1,200. You have also been asked to pay $35.28 for the remaining 20 visits for the 
additional methadone supplies, for a total of $705.60. The total for all services is $1,905.60. This item/service 
falls within the opioid treatment program 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 
copayments for opioid treatment services provided from January 8, 2022, to July 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the records show that the member does not meet Medicare guidelines for services 
in a skilled nursing facility. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the member remains medically stable and does not require skilled nursing and/or 
skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at a 
lower level of care. Although further rehab services would be appropriate to improve function, as a practical 
matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing 
facility. The member does not have any parental medication; complex wound care or nutrition given via a 
feeding tube. She is medically stable without any acute exacerbations of chronic medical problems. Her 
physical function is at or near her baseline and she can receive services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a gastroenterologist visit provided on June 
22, 2022. 
 
You asked the Plan to waive the copayment for a gastroenterologist visit. You say that you do not agree with 
the charges because the doctor's attitude and service was not professional. 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 $40 
copayment for each specialist visit or telehealth visit for Medicare-covered benefits.  
 
You have been asked to pay a $40 copayment for gastroenterologist visit. This item/service falls within the 
Physician/Practitioner services, including doctors office visits/specialist visit or telehealth visit for Medicare-
covered benefits. 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 gastroenterologist 
visit provided on June 22, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on July 27,2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says the enrollees network primary care physician (PCP) or plan must give 
the enrollee approval in advance before they can use providers not in the plan's network. This is called giving 
you a "referral." 
 
 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 mental health provided on July 27,2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient consultation provided on April 27, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an inpatient consultation. You say that this should have been 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 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 inpatient consultation provided on April 27, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractor services provided on April 13, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for chiropractor services. You say that you are appealing claim payment denial for 
services rendered. The Plan denied your request. The Plan says if the enrollee needs Medicare-covered medical 
care and a network provider is unable to provide this care, you may be able to get care from an out-of-network 
provider. Our plan must confirm there is not a network provider available, and the out-of-network provider 
must contract the plan to request an authorization for you to obtain services. If approved, the out-of-network 
provider will be issued an authorization to provide the service(s).  
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 chiropractor services provided on April 13, 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 coinsurance for injections on April 14, 2022, to May 08, 
2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you want to appeal the amount being 
charged. 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 9% 
coinsurance for Medicare Part B covered drugs. The provider billed in the amount of $12,920.11 and the 
allowed amount is $4,798.31. $4,798.31 x 9% = $431.85. There were two dates of service. $431.85 x 2 = 
$863.70. Therefore, results in the total cost sharing amount of $863.70. 
 
You have been asked to pay a 9% coinsurance for injections. This item/service falls within the Medicare Part B 
prescription drugs 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 injections on April 
14, 2022, to May 08, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network infusion procedure 
provided on January 13, 2022. 
 
You asked the Plan to waive the coinsurance for an out-of-network infusion procedure. You say that you did 
not have a procedure on this date of service. 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 20% 
coinsurance for outpatient hospital services. Your maximum out of pocket (MOOP) amount is $6700 for the 
year. A total of $819.96 has been applied to your 2022 MOOP. While you do have a 20% coinsurance on this 
service, you need to meet your MOOP first. 
 
You have been asked to pay a $819.96 coinsurance for an out-of-network infusion procedure. This item/service 
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 coinsurance for an out-of-network infusion procedure 
provided on January 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride and outpatient hospital 
observation provided from March 22, 2022, to March 31, 2022. 
 
You asked the Plan to waive the copayment for an ambulance ride and outpatient hospital observation. You say 
that you were told you had $1000 to use through your Plan for whatever medical needs you had. You would 
like a refund of that money as you now owe so much more. 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 must pay a $275 
copayment for ambulance services and a $295 copayment outpatient hospital observation ($275 x 2 ambulance 
rides = $550). $550 + $295 = a total copayment of $845. 
 
You have been asked to pay a $845 copayment for an ambulance ride and outpatient hospital observation. This 
item/service falls within the ambulance services and outpatient hospital observation 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 ambulance ride and outpatient hospital 
observation provided from March 22, 2022, to March 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for myelography provided on June 8, 2022. 
 
You asked the Plan to waive the coinsurance for a myelography, you say that you are requesting 
reconsideration stating the enrollee traveled 400 miles for the service then was charged $290.04. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 40% coinsurance for out-of-network advanced imaging. The enrollee has been asked to pay 40% 
coinsurance for myelography. The total allowed amount is $725.10, and 40% of $725.10 is $290.04. This 
item/service falls within the out-of-network advanced imaging 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 coinsurance for myelography provided on June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on June 17, 2023, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that the enrollee informed the office that he was covered 
under Medicare. Due to the patient misleading the office of incorrect insurance, the office was unable to obtain 
authorization. The Plan denied your request. The Plan says in the event the enrollee requires specialized 
services that are not available within our network, the enrollee must contact the plan to obtain prior 
authorization for out-of-network services. If the plan authorizes out-of-network services, the enrollees cost 
sharing for the out-of-network services will be the same as if the enrollee had received their care from a 
network provider. 
 
 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 17, 2023, by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on June 27, 
2022. 
 
You asked the Plan to waive the copayment for a breast ultrasound. You say that your provider requests an 
ultrasound every year due to the fact you have dense breast tissue. 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 $35 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $35 copayment for a breast ultrasound. 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 a breast ultrasound provided on June 27, 2022.