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

 
We decided that the Plan does not have to pre-approve cochlear implant surgery to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve cochlear implant surgery. You say that the in-network hospital is too far 
away to go to. The Plan denied your request. The Plan says because there is a facility within your network, per 
the Plan rules, services must be provided at that facility. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
cochlear implant surgery to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve outpatient mental health. You say that you received a notice of denial of 
medical coverage because it was out-of-network. The Plan denied your request. The Plan says the enrollee 
must receive their care from a network provider (for more information about this, see Section 2 in this chapter). 
In most cases, care the enrollee receives from an out-of-network provider (a provider who is not part of our 
plans network) will not be 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
outpatient mental health to be provided 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 skilled nursing facility care provided from 
January 1, 2022, to January 10, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility care. You say that this should be 
covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $184 
copayment for each day of skilled nursing facility care for days 21 to 100.  
 
The enrollee has been asked to pay a $184 copayment per day for 7 days of skilled nursing facility care, for a 
total of $1,288. The record shows that the enrollee was admitted to the facility on December 15, 2021, and 
stayed for a total of 27 days. The first 20 days were covered with no copayment. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing facility care provided from January 1, 2022, to January 10, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry 
services coded 83789 provided on June 1, 2022. 
 
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are 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. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 
 
In this case, the CPT Code Manual definition of code 83789 is mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, codes 80307 and G0480 
were previously paid by the Plan and both specifically include mass and chromatography. This means that code 
83789 it not separately payable as billed. In addition, the medical records provided do not show that the service 
billed with the -59 modifier is a distinct procedural service. Based on this information, we decided that 
Medicare rules for coverage of the mass spectrometry and tandem mass spectrometry services have not been 
met. Therefore, we decided that the Plan does not have to pay for the mass spectrometry and tandem mass 
spectrometry services coded 83789 provided on June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care visit provided on June 22, 
2022. 
 
You asked the Plan to waive the copayment for a primary care visit. You say that this should not have a 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for a primary care visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have 
to waive the copayment for a primary care visit provided on June 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biopsy services coded 20245 provided on September 21, 
2021. 
 
You asked the Plan to pay for the biopsy services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 20245 is biopsy, bone, open; deep (eg, humeral shaft, 
ischium, femoral shaft). 
 
 
 We find that CPT code 20245 is not supported in the medical record. Specifically, the documentation shows 
that biopsy, bone, open; superficial was performed. This means the documentation shows that there is a more 
appropriate code to be billed for the service provided. Based on this information, we decided that Medicare 
rules for coverage of the biopsy services have not been met. Therefore, we decided that the Plan does not have 
to pay for the biopsy services coded 20245 provided on September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit provided on June 15, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the annual wellness visit. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 annual wellness visit provided on June 15, 
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 burn care services provided on June 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the burn care services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says a referral/authorization was not obtained prior to services being 
rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 burn care services provided on June 10, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on March 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says a referral/authorization was not obtained prior to services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 genetic testing provided on March 9, 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 an outpatient visit to evaluate scooter needs provided on 
February 10, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient visit to evaluate scooter needs. You say that this service should be 
covered. The Plan denied your request. The Plan says there was no preauthorization (this is different than a 
referral) for an OON provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an outpatient visit to evaluate scooter needs 
provided on February 10, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on 
February 4, 2022, March 29, 2022, May 17, 2022, May 24, 2022, May 31, 2022, and June 09, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you would like the charges paid for 
because the insurance has approved these services. 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 20% 
coinsurance for Medicare-covered Part B drugs. The allowed amounts of these part B drugs total $1,418.70, 
resulting in a total coinsurance amount $283.74. 
 
You have been asked to pay 20% coinsurance for Part B drugs. This item/service falls within the Medicare-
covered Part B 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 Medicare 
Part B drugs provided on February 4, 2022, March 29, 2022, May 17, 2022, May 24, 2022, May 31, 2022, and 
June 09, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on June 28, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that this should be covered, you were the 
only provider available that day to see the beneficiary. The Plan denied your request. The Plan says there was 
no preauthorization (this is different than a referral) for an OON provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 skilled nursing facility visit provided on June 28, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays and magnetic resonance imaging 
(MRI) on July 19, 2021. 
 
You asked the Plan to waive the copayment for x-rays and MRI. You say that you were told that the services 
would be covered. 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 up to a 
$30 copayment for each Medicare-covered X-ray. You must pay up to a $50 copayment for each Medicare-
covered outpatient diagnostic procedure and test in an office setting or imaging center. Covered services 
include but are not limited to X-rays and other outpatient diagnostic radiological tests e.g., MRI's, CT's, PET 
scans. $30 for x-rays + $20 MRI = $50. Therefore, reuslts in the total cost sharing amount of $50.  
 You have been asked to pay a $30 copayment for x-rays and $20 copayment for MRI. This item/service 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 x-rays and magnetic resonance imaging (MRI) on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that authorization was obtained and approved. The Plan 
denied your request. The Plan says the prior authorization had expired before the date of service, and a new 
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 an office visit provided on May 24, 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 an office visit and injection provided on May 17, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and injection. You say that you were unaware that authorization 
was required. The Plan denied your request. The Plan says a referral/authorization was not obtained prior to 
services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit and injection provided on May 17, 
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 work provided on December 7, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that this should be covered. The Plan denied your request. The 
Plan says there was no preauthorization (this is different than a referral) for an OON provider or facility, and 
this was not an emergency. Therefore, the decision is upheld. 
 
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 lab work provided on December 7, 2021, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on May 09, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you were not aware of the requirement of obtaining a 
prior authorization. The Plan denied your request. The Plan says if the enrollee receives care from an out-of-
network provider (a provider who is not part of our plans network), such services will not be covered unless 
the enrollee obtains a 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 drug testing provided on May 09, 2022, by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast x-ray provided on June 22, 2022. 
 
You asked the Plan to waive the copayment for a breast x-ray. You say that this should be covered as a routine 
mammogram. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $55 
copayment for routine radiology (X-ray, radiology, diagnostic services, ultrasounds).  
 
You have been asked to pay a $55 copayment for a breast x-ray. This item/service falls within the routine 
radiology (X-ray, radiology, diagnostic services, ultrasounds) 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 breast x-ray provided on June 22, 2022.