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

We decided that the Plan does not have to waive the copayment for a specialist office visit (99204) provided on
October 5, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be
covered as you were advised to get a second opinion. The Plan denied your request. The Plan says the costsharing applied correctly based on the services provided.
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 $45
copayment for Physician/Practitioner services, including doctor's office visits.
You have been asked to pay a $45 copayment for a specialist office visit. Specialist office visits fall 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 (99204) provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist physician services provided 
from March 5, 2021, to October 29, 2021. 
 
You asked the Plan to waive the copayments for the specialist services. You say that in the past you only paid 
$5 for the services and you are on a limited income. 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 $35 
copayment for each visit for specialist services. 
 
The file shows you had a total of 9 visits for specialist services from March 5, 2021, to October 29, 2021. 
Therefore, you have been asked to pay a $35 copayment for each visit for the specialist services. The total for all visits is $315 ($35 copayment x 9 visits = $315). The specialist services fall 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 copayments for specialist physician services provided from March 5, 2021, to October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a physician visit provided on September 24, 2021, by an outof-network (OON) provider.
You asked the Plan to pay for a physician visit. You say that the physician provided medically necessary
services and you should not need a prior authorization. The Plan denied your request. The Plan says there was
no prior authorization or referral from an in-network provider for the enrollee to receive services from an outof-network provider. Also, the services provided were 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 physician visit provided on September 24, 2021,
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee 
from July 28, 2021, to September 8, 2021. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 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 Plan contract specifically states chiropractic care requires 
prior authorization.  
 
The 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 out of network physician services provided to the 
enrollee from July 28, 2021, to September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus-diphtheria-acellular pertussis (Tdap) vaccine
provided on September 7, 2021.
You asked the Plan to pay for the Tdap vaccine. You say that this should be covered. The Plan denied your
request. The Plan says this is not covered by Medicare Part B.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine.
The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine.
Therefore, we decided that the Plan does not have to pay for the tetanus-diphtheria-acellular pertussis (Tdap)
vaccine provided on September 7, 2021.
Benefits for the Tdap vaccine 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre continuous glucose monitoring
reader.
You asked the Plan to pre-approve the reader. You say that this is medically necessary. The Plan denied your
request. The Plan says you are not on insulin.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses
adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the reader
have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre
continuous glucose monitoring reader
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on October 14, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that the requests for this service accompanied by the 
actual specimen to be tested, are typically sent to you directly from the treating physician and you have no 
direct contact with the patient. You also say that there is no way of knowing if a pre-authorization is required 
prior to you processing the specimen. The Plan denied your request. The Plan says the referral was not 
authorized by the primary care provider (PCP). The Plan also says that this provider is not a network provider 
with the Plan. The Plan also say 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 laboratory testing provided on October 14, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment (98941) and electric 
stimulation therapy (97014) provided on October 19, 2021, to October 27, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for chiropractic manipulative treatment and electric stimulation therapy. You say 
that you have had visits to this same chiropractor for a long time and have never had a claim denied and the 
provider has tried multiple times to get an explanation as to why all of a sudden, the Plan is not paying these 
claims. 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 chiropractic manipulative treatment (98941) and 
electric stimulation therapy (97014) provided on October 19, 2021, to October 27, 2021, 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 rest home visit provided on July 29, 2021, by an out-ofnetwork (OON) provider.
You asked the Plan to pay for the rest home visit. You say that the service provided was medically necessary
and the facility failed to get an authorization for this service. The Plan denied your request. The Plan says there
was no authorization requested or obtained for the enrollee to receive services from an out-of-network
provider. Also, the services provided were 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 rest home visit provided on July 29, 2021, by an
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81479) provided on June 17, 2021. 
 
You asked the Plan to pay for laboratory services. You say that this is a covered service. The Plan denied your 
request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that as a general rule, the date of service of a 
laboratory test or service must be the date the specimen was collected. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to 
determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. The submitted documentation does not include medical records for 
the billed date of service. Based on this information, we decided that Medicare rules for coverage of laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services 
(81479) provided on June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 28, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the genetic testing provided on July 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
April 8, 2021 to April 9, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says outpatient services were delivered, not acute inpatient services. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee's readings did not meet criteria for hypertension urgency, and there was 
no evidence of organ damage related to high blood pressure. Therefore, lower level of care would have been 
appropriate, and it was not expected that the enrollee would require hospital care that would likely cross 2 
midnights based on the low severity and complexity of the 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided to the enrollee from April 8, 2021 to April 9, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility care provided from 
May 1, 2021, to May 24, 2021. 
 
You asked the Plan to waive the copayment for the skilled nursing facility care. You say that the services 
should be covered as you would not have received the services in the first place if you knew there would be a 
$50 copayment per day. The Plan denied your request. The Plan says the cost-sharing applied correctly based 
on the services provided. 
 
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 $50 
copayment each day for days 21 to 70 for Skilled Nursing Facility (SNF) Care.  
 You have been asked to pay a $50 copayment each day for days 21 to 41 of skilled nursing facility care ($50 x 
21 = $1,050). 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 skilled nursing facility care provided from 
May 1, 2021, to May 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient therapy services (97530) provided on October 12, 
2021. 
 
You asked the Plan to pay for outpatient therapy services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an OTA shall not be billed as 
services incident to a physician/NPP's service, because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of outpatient therapy services have not been met. Specifically, the documentation shows that this 
claim was billed by a nurse practitioner but the therapy services at issue were rendered by an Occupational 
Therapy Assistant. A Nurse Practitioner cannot bill for the services of an Occupational Therapy Assistant 
because a Nurse Practitioner does not meet the qualifications of a therapist. Therefore, we decided that the Plan 
does not have to pay for outpatient therapy services (97530) provided on October 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genomic sequence analysis panel (0242U) provided on 
June 28, 2021. 
 
You asked the Plan to pay for a genomic sequence analysis panel. You say that you were compliant with 
Medicare billing regulations. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a genomic sequence analysis panel have not been met. Specifically, this claim was billed with the 
laboratory place of service code while the records indicate that the members face-to-face service was rendered 
in an office setting. There is a more appropriate place of service code for the services billed. Therefore, we 
decided that the Plan does not have to pay for a genomic sequence analysis panel (0242U) provided on June 28, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an ultrasound of the head and neck provided 
on August 2, 2021. 
 
You asked the Plan to waive the deductible for the ultrasound. You say that the copayments should apply 
instead of the deductible. The Plan denied your request. The Plan says the correct amount was applied to your 
deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $1,000 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $1,000 deductible which applies to Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies.  This cost sharing is a contractual obligation that had not been met at the time the ultrasound was received on 
August 2, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an ultrasound of 
the head and neck provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on 
September 17, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that it is the nursing facility's 
responsibility to get authorizations for their patients. You also say that it was medically necessary for the 
patient to receive the treatment by the provider, and you did not know that the facility failed to get 
preauthorization for this patient, so you treated the patient anyway. The Plan denied your request. The Plan 
says this provider is out-of-network with the Plan, and authorization was not obtained prior to the services 
being rendered. The Plan also says that prior authorization is required from the Plan for this disputed service to 
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 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 (99336) provided 
on September 17, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (S1015, S8301) provided August 19, 
2021. 
 
You asked the Plan to pay for the anesthesia services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the codes billed cannot be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 
 We find that CPT codes S1015, & S8301 are not supported in the medical record. Specifically, per the National 
Physician Fee Schedule, the codes billed have a status of "I" and are invalid for Medicare payment. Based on 
this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. 
Therefore, we decided that the Plan does not have to pay for anesthesia services (S1015, S8301) provided 
August 19, 2021.