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

 
We decided that the Plan does not have to pay for physician's services provided on October 14, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior 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 did not pre-approve the 
service 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 physician's services provided on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
February 22, 2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you only received lab results 
and you do not feel you should pay for a visit that was not necessary. 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 $40 
copayment for each specialist visit.  
 
 
 
 
 
 
 You have been asked to pay $35.80, which is less than the $40 copayment for the specialist visit. The specialist 
visit falls 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 a specialist office visit provided on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 1, 2022. 
 
You asked the Plan to pay for physician's services. 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 physician's services provided on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232-25 billed for date of service April 17, 
2022. 
 You asked the Plan to pay for procedure code 99232. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says this code is 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 CPT code. In this case, we have confirmed that code 99232 
is a column II code to column I code 99233 with a modifier indicator of 0. In addition, we find that procedure 
code 99233 was billed by a physician of the same specialty in the same billing group.  Only one Evaluation and 
Management service per day is permitted in this scenario, particularly because code 99232 has a indicator of 0, 
meaning that there are no modifiers allowed that would permit separate payment of this code. The column II 
code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99232-25 billed for date of service 
April 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manual wheelchair and equipment provided on February 8, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for manual wheelchair and equipment. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
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 manual wheelchair and equipment provided on 
February 8, 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 (82728, 83540, 83550) provided January 20, 
2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says rules for coverage are not met. 
 
 
 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
lab services (82728, 83540, 83550) provided January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that this is necessary for the enrollee's 
condition. The Plan denied your request. The Plan says a total electric hospital bed is not covered by Medicare 
or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdominal aortic aneurysm (AAA) ultrasound screening 
(76706) provided on March 28, 2022. 
 
You asked the Plan to pay for the AAA screening. You say that this service was necessary, and the diagnoses 
billed on this claim are appropriate per Local Coverage Article A55071. The Plan denied your request. The 
Plan says this claim was not billed with an appropriate diagnosis for the service at issue. The Plan also argues 
that the coverage article cited by the provider does not apply to the state where these services took place. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules state that a one-time ultrasound AAA screening is covered for 
beneficiaries who meet certain criteria. 
 
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 the AAA screening. Our reviewer says that 
the criteria for coverage of an ultrasound AAA screening are not met in this case. Our physician reviewer found 
that there is no documentation provided to show that the enrollee meets all of the above criteria for the 
screening abdominal ultrasound performed on March 28, 2022. Provided records do not document a family 
history of abdominal aortic aneurysm, that the enrollee is a man between the ages of 65 to 75 who has smoked 
at least 100 cigarettes, or that there are other risk factors recommended for screening by the United States 
Preventive Services Task Force regarding abdominal aortic aneurysm. In addition, Local Coverage 
Article A55071 does not apply to Florida; the health plan is correct that this does not apply in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the AAA screening have not been met. Therefore, we decided that the Plan does 
not have to pay for an abdominal aortic aneurysm (AAA) ultrasound screening (76706) provided on March 28, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on  
January 25, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
services from non-participating providers are not covered unless preauthorized. 
 
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 subsequent nursing facility care provided on January 25, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on February 3, 
2022. 
 
You asked the Plan to pay for the hospital care. You say that the enrollee was not enrolled in hospice on the 
date of service in this case. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 2, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care (99232) provided on February 3, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer for teeth #28, 29, and 31 (D6548). 
 
You asked the Plan to pre-approve a retainer for teeth #28, 29, and 31. You say that the services are necessary. 
The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
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 pre-approve a 
retainer for teeth #28, 29, and 31 (D6548).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) of the 
brain (70553) provided on March 28, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that you needed a second MRI because the 
first one was not definitive, and you will require additional testing and treatment. The Plan denied your request. 
The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your 
contract. 
 
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 $200 
copayment for each advanced imaging service.  
 
You have been asked to pay a $200 copayment for the MRI. An MRI falls within the advanced imaging service 
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 magnetic resonance imaging 
(MRI) of the brain (70553) provided on March 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 3, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a denosumab injection provided on March 
10, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were not informed of any cost 
sharing for the service. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 Part B drugs.  
 
You have been asked to pay $254.52, which is 20% of the allowed amount for the injection ($1,272.60 allowed 
amount x 20% coinsurance = $254.52). The 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 10, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on November 21, 
2021, to November 22, 2021. 
 
You asked the Plan to waive the copayment for emergency room services. You say that it should be covered in 
full. 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 $90 
copayment for each emergency room visit in the U.S. Emergency care refers to services that are: furnished by a 
provider qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical 
condition. 
 
You have been asked to pay a $90 copayment for emergency room services. Emergency room services fall 
within the Emergency 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 emergency 
room services on November 21, 2021, to November 22, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services provided on June 29, 2021. 
 
You asked the Plan to pay for the lab services. You say that this is not a duplicate claim because it was billed 
with the -59 modifier. The Plan denied your request. The Plan says that you did not report a taxonomy code on 
your claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole basis for denial is that there is a missing taxonomy 
code on your claim.  However, the Plan has failed to provide a copy of the claim you submitted in the case file 
it sent to us.  Without a copy of this claim, we cannot determine if the claim submitted was deficient in any 
way.  We also cannot determine if the claim was a duplicate and/or if the modifiers appended were appropriate. 
Therefore, we decided that the Plan has to pay for lab services provided on June 29, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing (80307 G0483) provided on March 
23, 2022 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 (80307 G0483) provided 
on March 23, 2022 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care provided on February 17, 2022. 
 
You asked the Plan to pay for initial nursing facility care. The Plan denied your request. The Plan says this 
provider is not contracted with the Plan and prior authorization was not obtained for this date of service. 
 
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 initial nursing facility care provided on February 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve DecisionDx-Melanoma testing (81529) provided on 
April 14, 2022. 
 
You asked the Plan to pre-approve DecisionDx-Melanoma testing. You say that this is a covered benefit. The 
Plan denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a molecular diagnostic service, 
providers must enter the appropriate DEX Z-Code identifier adjacent to the procedure code in the 
comment/narrative field.  
 
We looked at the file and Medicare rules. This molecular diagnostic service was not reported with a DEX Z-
code. Based on this information, we decided that Medicare rules for coverage of DecisionDx-Melanoma testing 
have not been met. Therefore, we decided that the Plan does not have to pre-approve DecisionDx-Melanoma 
testing (81529) provided on April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on October 11, 2021 by an out-of-
network (OON) provider. 
 You asked the Plan to pay for the medical services. You say that the provider did not get authorization to 
provide these specific medical services because a different service was originally intended.  Due to diagnostic 
findings, a different service ended up being medically necessary. The Plan denied your request. The Plan says 
unauthorized, non-plan care is not covered.  The service provided was not authorized. Further, code 36140 is 
not payable when separately reported. 
 
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. 
 
Theprovider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. In addition, Medicare coding rules explicitly state that code 36140 is not a separately reportable code.  
Code 36140 is the only code you billed. 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 medical services provided on 
October 11, 2021 by an out-of-network (OON) provider.