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

 
We decided that the Plan does not have to pay for laboratory drug testing (G0482) provided on August 10, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory drug testing. 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 drug testing (G0482) provided on 
August 10, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from February 15, 2022, to March 4, 2022. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you were told you requested a 
private room of which you did not. The Plan denied your request. The Plan says the copayment was 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 $0 
copayment each day for Medicare-covered days 1 to 20 and a $50 copayment each day for Medicare-covered 
days 21 to 70.  
 
 
  You have been asked to pay $700 ($50 copay x 14 days) for the SNF stay. The SNF stay falls within the 
Skilled Nursing Facility (SNF) Care 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 
skilled nursing facility (SNF) stay provided from February 15, 2022, to March 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 18, 2022, billed 
with codes 81227, 81230, 81231, 81232, 81306, 81328, 81355, 81335, 0031U, 0032U and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare coding regulations. 
 
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 
February 18, 2022, billed with codes 81227, 81230, 81231, 81232, 81306, 81328, 81355, 81335, 0031U, 
0032U and 0033U.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient procedures provided from 
January 21, 2022, to April 15, 2022. 
 
You asked the Plan to waive the copayments for outpatient procedures. You say that these were billed 
incorrectly. The Plan denied your request. The Plan says the copayments applied are 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 $295 
copayment for each Medicare-covered outpatient hospital facility visit. 
 
You have been asked to pay a total of $1,051.98 which is less than the standard $295 copayment for each 
outpatient procedures. Outpatient procedures falls within the Outpatient Surgery, Including Services Provided 
at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayments for outpatient procedures provided from January 21, 2022, to April 15, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90834) provided February 
7, 2022. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed services. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient mental health services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for outpatient mental health 
services (90834) provided February 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cystourethroscopy, an exam of the 
bladder and urethra using an endoscope provided on March 1, 2022. 
 
You asked the Plan to waive the copayment for the cystourethroscopy. You say that you were seen in the same 
doctors office. You say that you were not told that this would be considered an outpatient surgery. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $325 
copayment for an outpatient hospital facility visit.  
 
You have been asked to pay a $325 copayment for an outpatient hospital facility visit. The cystourethroscopy 
falls within the Outpatient Hospital Services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the cystourethroscopy, an exam of the bladder and urethra using an endoscope provided on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service December 
13, 2021. 
 You asked the Plan to pay for procedure code 99053. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99053 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99217) provided January 1, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed code. 
 
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 99217 is Observation care discharge day management. 
 
We find that CPT code 99217 is not supported in the medical record. Specifically, discharge day services are 
not supported as the record shows no claim for an initial or subsequent observation service. Based on this 
information, we decided that Medicare rules for coverage of the physician services have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services (99217) provided January 1, 
2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from January 5, 2022, to 
April 6, 2022. 
 
You asked the Plan to pay for psychotherapy services. The Plan denied your request. The Plan says services 
from non-participating providers are not covered under your Plan unless they are authorized by the Plan before 
the services are provided. 
 
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 psychotherapy services provided from January 5, 2022, to  
April 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for electrocardiogram on March 24, 2022. 
 
You asked the Plan to waive the deductible for electrocardiogram. 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. Your 
contract with the Plan says that there is a $500 deductible which applies to Outpatient hospital services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
hospital services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 
deductible which applies to Outpatient hospital services. This cost sharing is a contractual obligation that had 
not been met at the time electrocardiogram was received on March 24, 2022. Therefore, we decided that the 
Plan does not have to waive the deductible for electrocardiogram on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the wound care services provided on 
February 7, 2022. 
 
You asked the Plan to waive the copayment for the wound care services. You say that you will require surgery 
soon in order to keep the infection from returning. You say you do not have the $225 that has been charged. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 ambulatory surgical services.  
 
You have been asked to pay a $225 copayment for ambulatory surgical services. Ambulatory surgical services 
fall 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 the wound 
care services provided on February 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care physician visit provided on 
March 28, 2022, and April 12, 2022. 
 
You asked the Plan to waive the copayment for a primary care physician visit. You say that you should not 
have to pay these copayments as they were short phone visits lasting less than 10 minutes. The Plan denied 
your request. The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
copayment for physician/practitioner services.  
 
You have been asked to pay a $10 copayment for primary care physician visits ($5 + $5 = $10). A primary care 
physician visit falls within the Physician/Practitioner Services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a primary care physician visit provided on March 28, 2022, and April 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient cataract surgery (66984) 
provided at an ambulatory surgical center on March 23, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you were advised by your 
provider that you would only have to pay $150, and you do not think you should be responsible for the rest. 
The Plan denied your request. The Plan says the copayment was applied correctly. Furthermore, the Plan 
contacted the provider and confirmed the facility you went to is a free-standing outpatient clinic, otherwise 
known as an ambulatory surgical center. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for all other Ambulatory Surgical Center (ASC) services.  
 
You have been asked to pay a $275 copayment for outpatient surgery. The services at issue fall 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 cataract surgery (66984) provided at 
an ambulatory surgical center on March 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract removal surgeries (66984) and ophthalmic 
biometry (92136) provided on March 4, 2022, to March 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the cataract removal surgeries and ophthalmic biometry. You say that you were 
told from your broker that this provider was in-network. 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 cataract removal surgeries (66984) and 
ophthalmic biometry (92136) provided on March 4, 2022, to March 18, 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 chiropractic and acupuncture services provided to the 
enrollee from January 11, 2022, to March 21, 2022.  
You asked the Plan to pay for the services. You say that the claim should be reprocessed. The Plan denied your 
request. The Plan says the claims were processed correctly for denial. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The rules say that acupuncture services are only 
covered for chronic low back pain. 
 
There are a variety of codes and denial reasons in this case. 
 
The acupuncture codes (20560 and 20561) are denied as they were billed for a diagnosis of M99.03 - segmental 
and somatic dysfunction of the lumbar region. Acupuncture services are only covered for a diagnosis of chronic 
low back pain under specific circumstances. 
 
Chiropractic procedure code 98941 can be covered if active treatment is taking place for a subluxation of the 
spine. However, the modifier AT needs to be attached to the claim for coverage. The claim did not have the AT 
modifier. 
 
The remainder of the chiropractic codes - G0283 (electrical stimulation), 97012 (application of a modality, 
traction, mechanical), 97124 (therapeutic procedure, massage) and 29200 (strapping, thorax) are not covered as 
the only chiropractic services that are covered are related to manual manipulation of the spine to correct 
subluxation.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for 
chiropractic and acupuncture services provided to the enrollee from January 11, 2022, to March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on March 23, 2022. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that this provider is the contracted 
dermatologist for the facility. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 
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 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 a domiciliary or rest home visit provided on March 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a visual field exam provided on  
February 22, 2022. 
 
You asked the Plan to waive the copayment for a visual field exam. You say that the cost of your visit has 
increased since 2021. You say that you believe you should not be billed the additional $27. The Plan denied 
your request. The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for diagnostic procedures and tests, including ultrasounds, at all in-network locations of service.  
 
You have been asked to pay a $75 copayment for a visual field exam ($48 + $27). A visual field exam 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 visual field exam provided on February 22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the therapy visit provided on February 8, 
2022. 
 
You asked the Plan to waive the copayment for the therapy. You say that you cannot afford to pay the $35 
copayment as you are on a fixed income. The Plan denied your request. The Plan says the copayment was 
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 $35 
copayment for Medicare-covered occupational therapy, physical therapy, and speech and language pathology 
visits.  
 
 
  You have been asked to pay $35 for the therapy visit. The therapy visit falls within the Outpatient 
Rehabilitation 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 the therapy 
visit provided on February 8, 2022.