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

 
We decided that the Plan does not have to pay for ultrasound provided on November 10, 2021. 
 
You asked the Plan to pay for ultrasound. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for ultrasound provided on 
November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for therapy visits provided on June 23, 2020, 
to December 3, 2021 
 
You asked the Plan to reduce the copayment for therapy visits. You say that you are requesting to reduce the 
copayments. 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 $35 
copayment for outpatient mental health care.  
 
The Special Supplemental Benefits for the Chronically Ill (SSBCI) program with reduced outpatient mental 
health cost-sharing was not offered prior to the 2022 plan year. 
 
You have been asked to pay $35 copayment for each therapy visit. This item/service falls within the outpatient 
mental health 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 reduce the copayment for therapy visits 
provided on June 23, 2020, to December 3, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for polycarbonate lens (V2784), oversized lens (V2780) and photochromatic lens (V2744) provided on September 20, 2022.

You asked the Plan to pay for polycarbonate lens (V2784), oversized lens (V2780) and photochromatic lens (V2744). You say that you were referred to this provider by a Plan representative. You also say you thought that all services would be covered if you went with an in-network specialist. The Plan denied your request. The Plan says these services were denied as not a covered benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when you get a single vision or lines multi-focal lens. The lens enhancements that you received are not covered.

We looked at the file and the Plan's rules. The Plan rules say that the eyeglasses allowance covers standard eyeglasses, single vision, or lined multi-focal lens and frame. The Plan rules also say that enhancements including polycarbonate lens (V2784), oversized lens (V2780) and photochromatic lens (V2744) are not covered through the allowance but may be purchased by you at an additional cost. Based on this information, we decided that the Plan's rules for coverage of polycarbonate lens (V2784), oversized lens (V2780) and photochromatic lens (V2744) have not been met. Therefore, we decided that the Plan does not have to pay for polycarbonate lens (V2784), oversized lens (V2780) and photochromatic lens (V2744) provided on September 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service August 1, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the number of 
units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99497 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99497 
billed for date of service August 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for lab services provided on September 19, 
2022. 
 
You asked the Plan to waive the deductible for lab services. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $25.73 
deductibles for annual preventative physical exam.  
 
You have been asked to pay $25.73 deductibles for lab services. This item/service falls within the annual 
preventative physical exam 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 deductible for lab services 
provided on September 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from January 11, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from January 11, 2023, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from January 
11, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of January 11, 2023, forward. Our physician reviewer found the 
enrollee did not require inpatient mental health treatment beyond January 11, 2023, as she was not a danger to 
herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollee's condition or for the 
purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from January 11, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from January 11, 
2023, forward.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for codes 88361, 88312, 88305, and 88112 provided on January 19, 2022. 
 
You asked the Plan to pay for codes 88361, 88312, 88305, and 88112. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says that the services billed are not supported. 
 
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. Review of the file shows that the Plan states that additional information such as 
laboratory results, name of laboratory who performed the service, etc. was necessary to process payment for 
this claim. However, the documentation included a Test Requisition Form and laboratory results. No other 
valid denial rationale was presented by the Plan. The Plan did not substantiate their denial. Therefore, we 
decided that the Plan has to pay for codes 88361, 88312, 88305, and 88112 provided on January 19, 2022.  
 
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: 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 the enrollee needs SNF care. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for a SNF admission. 
 
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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided on April 14, 2022, to May 12, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for home health care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not authorized by the primary care 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 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 home health care provided on April 14, 2022, to 
May 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 the genetic testing provided on August 2, 2022, billed with 
codes 81314, 81321 and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported as billed. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
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 
August 2, 2022, billed with codes 81314, 81321 and 81351.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81292) provided on May 17, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that this testing was medically necessary and 
reasonable. The Plan denied your request. The Plan says these services were referred by and performed by out-of-network providers. Out-of-network care is only covered in certain limited circumstances which have not 
been met in this case. 
 
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 (81292) provided on May 17, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a magnetic resonance imaging (MRI) scan of the breasts provided on 
August 17, 2022. 
 
You asked the Plan to pay for the MRI. You say that the services should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says that the services denied correctly as they are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the service 
is not medically necessary. Our physician reviewer found that the enrollees BRCA-2 mutation is an indication 
for annual MRI screenings and since the enrollee has had bilateral breast cancer the fact the enrollee has a 
finding of some concern on the MRI, makes it a valid indication for a 6-month follow-up exam. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pay for a 
magnetic resonance imaging (MRI) scan of the breasts provided on August 17, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) provided on August 22, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99204) provided on August 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy, implanted pump pain management 
infusion provided on September 10, 2022. 
 
You asked the Plan to pay for home infusion therapy, implanted pump pain management infusion. You say that 
you are appealing the claim payment denial. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home infusion therapy, 
implanted pump pain management infusion provided on September 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 24, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service October 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87801-59, 87634, and 87640 billed for date 
of service January 4, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the claim denied 
correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, we have confirmed that code 87640 is a column II code to column I code 87641. We also 
confirmed that code 87634 is a column II code to column I code 87632. Codes 87640 and 87634 were not 
billed with an appropriate modifier to bypass the edit. Based on this information, we decided that the Medicare 
rules for coverage have not been met. 
 
The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or 
claim line are denied. We looked at the file and Medicare rules. The file shows that 2 units of procedure code 
87801 was reimbursed by the Plan on February 7, 2022. There is no evidence to support that additional services 
were provided on the same date. Based on this information, we decided that the Medicare rules for have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87801-59, 87634, and 
87640 billed for date of service January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit, intralesional injection, and triamcinolone 
acetonide injection provided on May 25, 2022. 
 
You asked the Plan to pay for office visit, intralesional injection, and triamcinolone acetonide injection. You 
say that you are appealing the claim payment denial. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit, intralesional 
injection, and triamcinolone acetonide injection provided on May 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital observation care provided on March 01, 2022. 
 
You asked the Plan to pay for initial hospital observation care. You say that the provider is not responsible for 
obtaining authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for initial hospital 
observation care provided on March 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care billed under codes A6212 and A6196 provided 
on September 26, 2022. 
 
You asked the Plan to pay for wound care billed under codes A6212 and A6196. You say that you are 
appealing the claim payment denial. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care billed under 
codes A6212 and A6196 provided on September 26, 2022.