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

 
We decided that the Plan does not have to pay for laboratory services (36415, 85379, 85025, 80053) provided 
on February 28, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
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 laboratory services (36415, 85379, 85025, 80053) 
provided on February 28, 2022 by an out-of-network (OON) provider.
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 4, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you had 
passed out, were fine when the ambulance arrived, and did not believe transportation to the hospital was 
necessary. The Plan denied your request. The Plan says this service is not covered because you were not 
transported by ambulance. 
 
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 4, 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 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the records show that while the enrollee requires rehabilitation services, they can be 
provided 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic comprehensive preventive medicine reevaluation 
and services provided on June 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a periodic comprehensive preventive medicine reevaluation and services. You 
say that you are appealing with supporting records. The Plan denied your request. The Plan says this provider is 
not a network provider with the Plan. The Plan also says that these services were pre-approved in advanced. 
 
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 a periodic comprehensive preventive medicine 
reevaluation and services provided on June 9, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81227, 81230, 81231, 81232, 81306, 81335, 
81355, 81291, 0031U, 0032U, 0033U, 81407, 81238, 81291) provided April 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that only the following codes should be billed for 
Cardiovascular Disease Screening: 80061 (Lipid panel) 82465 (Cholesterol, serum or whole blood, total), 
83718 (Lipoprotein, direct measurement; high density cholesterol) and/or 84478 (Triglycerides). 
 
We looked at the file and Medicare rules. The cardiovascular genetic screening is not a covered service. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81227, 81230, 81231, 81232, 81306, 
81335, 81355, 81291, 0031U, 0032U, 0033U, 81407, 81238, 81291) provided April 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract surgery provided on May 16, 2022, and  
June 1, 2022. 
 
You asked the Plan to pay for cataract surgery. The Plan denied your request. The Plan says the member self-
referred himself to this out-of-network ophthalmologist to have the cataract surgery with no authorization or 
outreach to the Health Plan. There is several ophthalmologist providers closer to the members address that 
could have provided the services. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for cataract surgery provided on May 16, 2022, and June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth specilist visit provided on May 
27, 2022. 
 
You asked the Plan to waive the copayment for a telehealth specilist visit. You say that you thought this was a 
courtesy call, not a billable one. 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 Physician/Practitioner services, including doctors office visits. 
 
 
 
 
 
 
 You have been asked to pay a $40 copayment for a telehealth specilist visit. This item/service falls within the 
Physician/Practitioner services, including doctors office visits 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 telehealth specilist visit provided on May 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on June 9, 2022. 
 
The enrollee asked the Plan to pay for the surgical extraction. The enrollee said that they had to go to an oral 
surgeon to have a tooth removed because it was broken and hollowed out. The Plan denied your request. The 
Plan says this is not a covered service under the enrollee's plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
surgical extraction (D7210) provided on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions provided from April 19, 2022, to May 10, 
2022.  
 
You asked the Plan to pay for the extractions. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says your annual dental benefit has been exhausted. 
 
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 this benefit includes 
coverage up to $2,500 for non-Medicare covered preventive and comprehensive dental services. The record shows your annual dental benefit has been exhausted. You are responsible for any amount above 
the benefit limit. Extractions fall within the Dental 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 pay for the extractions provided from April 19, 2022, to May 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Denosumab injection provided on March 
11, 2022 
 
You asked the Plan to waive the coinsurance for a Denosumab injection. You say that you did not realize there 
would be a coinsurance for this service and did not think to ask. You also say you cant afford to pay this. The 
Plan denied your request. The Plan says the cost share has been applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for chemotherapy drugs, infusion drugs, and all other drugs covered under Medicare Part B.  
 
 
 
 
 
 You have been asked to pay $293.77 for a Denosumab injection. A Denosumab injection 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 a 
Denosumab injection provided on March 11, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on April 05, 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 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 $45 
copayment for provider and professional services at specialists office. Covered services include consultation, 
diagnosis, and treatment by a specialist.  
 
You have been asked to pay a $45 copayment for office visit. Office visits fall within the Physician/practitioner 
services, including doctor's office visits 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 office visit on April 05, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on February 26, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. 
The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there is no 
payable service. 
 
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 February 26, 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 ambulance response and treatment, no transport 
(A0998) provided on February 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like the claim reprocessed. The Plan 
denied your request. The Plan says the rendering provider is an OON provider and there was no approved 
authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on April 27, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted multianalyte assay with algorithmic analysis, 
PrismRA genetic testing (81599) provided May 4, 2022. 
 
You asked the Plan to pay for PrismRA genetic testing. You say that you are requesting reconsideration of the 
denial for the PrismRA test because you are the only CLIA certified lab able to run this test. The Plan denied 
your request. The Plan says based on the diagnostic program, MolDX coverage determination indicated on the 
DEX Diagnostics Exchange Registry, the requested test PrismRA is not a covered test. 
 
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 pay for PrismRA genetic testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that the PrismRA 
genetic testing provided on May 4, 2022 at issue in this case meets all Medicare criteria for medically 
reasonable and necessary. The provided medical records do not document that the test results would provide 
the clinician with information that would improve patient outcomes and/or change physician care and treatment 
of the patient as required by the Local Coverage Determination (LCD) MolDX: Molecular Diagnostic Tests 
(MDT) L35025. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PrismRA genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pay for unlisted multianalyte assay with algorithmic analysis, PrismRA genetic testing 
(81599) provided May 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve self-adherent bandage, elastic, non-knitted/non-woven, 
width greater than or equal to 3 inches and less than 5 inches, per yard (A6454) and zinc paste impregnated 
bandage, non-elastic, knitted/woven, width greater than or equal to 3 inches and less than 5 inches, per yard 
(A6456) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve wound care supplies. You say that you are appealing the denial because you 
were instructed by your surgeon to start using the twice weekly unna boot on at a medical visit. The Plan 
denied your request. The Plan says enrollees must receive their medical services from an in-network provider 
with the exception being urgent or emergent services. Non-emergent services with non-contracted providers 
require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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. Medicare rules 
also say that compression bandages and gradient compression wraps are covered only when they are used as 
dressings over a qualifying wound. 
 
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. Additionally, the records do not show that 
the enrollee is being treated for open venous stasis ulcers to meet the requirement for zinc past impregnated 
bandages and compression wraps (unna boots). 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 self-adherent 
bandage, elastic, non-knitted/non-woven, width greater than or equal to 3 inches and less than 5 inches, per 
yard (A6454) and zinc paste impregnated bandage, non-elastic, knitted/woven, width greater than or equal to 3 
inches and less than 5 inches, per yard (A6456) to be provided 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 April 20, 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 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 $225 
copayment for each Medicare-covered trip (one-way).  Covered ambulance services include fixed wing, rotary 
wing, and ground ambulance services, to the nearest, appropriate facility that can provide care only 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. 
 
 
 
 
 
 You have been asked to pay a $225 copayment for ambulance. Ambulance falls within the Ambulance 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 ambulance on April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the orthopedic services. You say that the services should be covered as you 
disagree with the denial. 
 The Plan denied your request. The Plan says the services denied correctly as they are non-emergent and can be 
provided in-network. 
 
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 
orthopedic services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 19, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service May 19, 2022.