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

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on April 4, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that the Plan incorrectly stated the 
type of policy you have, and processed the claim without catching the mistakes. You also say that the enrollee 
should not be charged for it. The Plan denied your request. The Plan says you were 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 $35 
copayment for laboratory services in an urgent care center and outpatient hospital.  
 
You have been asked to pay a $35 copayment for laboratory services. Laboratory services 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 laboratory services provided on April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided from January 8, 2022, to March 19, 
2022. 
 
You asked the Plan to pay for acupuncture. You say that you have a small tremor in your left hand and when 
you get acupuncture the tremor goes away for a couple weeks. The Plan denied your request. The Plan says 
acupuncture for the treatment of conditions other than chronic lower back pain is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, acupuncture for the treatment of conditions other than 
chronic lower back pain is not covered by Medicare. Therefore, we decided that the Plan does not have to pay 
for acupuncture provided from January 8, 2022, to March 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from June 19, 
2021, to June 23, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not follow Medicare home health guidelines. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report home health services with a timely Request for Anticipated payment. 
 
The Request for Anticipated Payment was submitted on September 16, 2021, which is more than five days 
from the start of care. 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 home health services provided 
to the enrollee from June 19, 2021, to June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit and ear exam provided on 
December 27, 2021. 
 
You asked the Plan to waive the cost share for an office visit and ear exam. You say that you are being 
overcharged because you have never paid more than the $15 copayment in the past. The Plan denied your 
request. The Plan says the cost share applied 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 $25 
copayment for non- radiological diagnostic services and $15 copayment for services obtained from a specialist.  
 
 You have been asked to pay a total of $40 copayment for an office visit and ear exam. Ear exams fall within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category.  The office visit 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 cost share for an office visit and ear exam provided on December 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a biopsy provided on March 18, 2022. 
 
You asked the Plan to waive the copayment for a biopsy. You say that you should not have a copayment that is 
this high. 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 $115 
copayment for other outpatient diagnostic tests.  
 
You have been asked to pay the allowed amount of $80.79 which is less than the $115 copayment for a biopsy. 
A biopsy falls within the Other Outpatient Diagnostic Tests 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 biopsy provided on March 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a respiratory molecular pathogen panel provided to the 
enrollee on October 5, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says multiplex panels of six or more pathogens are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that multiplex polymerase chain reaction (PCR) 
respiratory viral panels of 6 or more pathogens are non-covered.  
 
Too many pathogens were tested to make this panel coverable by Medicare. 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 a respiratory molecular pathogen panel provided to the enrollee on October 5, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that you have been in mental health counseling with this 
provider for five or six years, you have a disability, heart issues, depression, anxiety, stomach and urinary 
issues, and you are on four different heart medications. You also say that since your income is limited due to 
being on social security disability, you are seeking patricidal reimbursement for this session. The Plan denied 
your request. The Plan says the service was rendered by a non-participating provider without 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 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 psychotherapy provided on March 1, 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 a domiciliary or rest home visit and transitional care 
management services provided on February 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit and transitional care management services. You 
say that authorization was not obtained prior to seeing this patient since it is the nursing facility's responsibility 
to get authorizations for the patients. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan. The Plan also says that they have 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 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 domiciliary or rest home visit and transitional 
care management services provided on February 8, 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 subsequent nursing facility care provided on February 9, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that your doctor is a hospitalist 
physician and depends upon the hospital staff to verify the eligibility and to obtain proper authorization from 
the patient's insurance company. The Plan denied your request. The Plan says services from non-participating 
providers are not covered under open access 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 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 subsequent nursing facility care provided on 
February 9, 2022, 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 April 29, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says a modifier was not billed on the claim to represent the services as separate/distinct. 
 
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 April 29, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 7, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this provider was the reading radiologist and 
payment should not have been made to another provider. You say that there should be two separate claims on 
file and this claim should be reprocessed for payment. 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 March 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mesalamine 1000mg suppository. 
 
You asked the Plan to pre-approve Mesalamine 1000mg suppository. You say that the medication is necessary. 
The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a 
separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Mesalamine 1000mg 
suppository.  
 
Benefits for Mesalamine 1000mg suppository may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service March 26, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that this should be paid for. The Plan denied 
your request. The Plan says the enrollee had multiple exams on this date of service. 
 
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 70544 
is a column II code to column I code 70553. 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 70544 billed for date of service March 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic comprehensive preventive medicine reevaluation 
and management of an individual provided on April 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a periodic comprehensive preventive medicine reevaluation and management of 
an individual. You say that you are appealing with supporting records. The Plan denied your request. The Plan 
says services from non-participating providers are not covered under open access 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 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 management of an individual provided on April 6, 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 the nursing facility care (99307) provided on January 10, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing care. You say that this service should be covered under the umbrella 
of the facility authorization. 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 nursing facility care (99307) provided on 
January 10, 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 a home visit, debridement of nails, and excision of nails 
provided on March 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a home visit, debridement of nails, and excision of nails. You say that it was 
medically necessary to treat the enrollee and you would like the claim to reprocessed for payment. The Plan 
denied your request. The Plan says the rendering provider is an OON provider and there was no referral from 
an in-network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 home visit, debridement of nails, and excision of 
nails provided on March 23, 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 physician services (99309) provided on January 3, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says there were network providers available. The out-of-network services 
were not pre-authorized. 
 
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 services at issue in this appeal. 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 services (99309) provided on January 3, 2022 by an out-of-
network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for infliximab injection provided on April 20, 
2022. 
 
You asked the Plan to waive the coinsurance for infliximab injection. You say that you were told by a customer 
service representative prior to starting the treatment, that intravenous (IV) infusion therapy is covered with no 
patient responsibility. The Plan denied your request. The Plan says coinsurance 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 20% 
coinsurance for Medicare-covered Part B chemotherapy drugs and other Part B drugs. Medicare Part B drugs 
may be subject to step therapy requirements. 
  You have been asked to pay $346.32, which is 20% of the allowed amount for the infliximab injection. The 
allowed amount is $1,731.60 (20% x $1,731.60 = $346.32). Infliximab 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 infliximab 
injection provided on April 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the abdomen and 
pelvis with contrast (74177) provided on March 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a CT scan of the abdomen and pelvis with contrast. You say that you want the 
Plan to reconsider the denied charges for payment. The Plan denied your request. The Plan says the services are 
not covered from non-participating providers unless they are pre-authorized. 
 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 computed tomography (CT) scan of the 
abdomen and pelvis with contrast (74177) provided on March 15, 2022, by an out-of-network (OON) provider.