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

We decided that the Plan does not have to pay for the services (CPT code(s): A4649, A4550, A4556, A4557, 
S8301, S1015, 99072) provided to the enrollee on March 17, 2021. 
 
You asked the Plan to pay for the services. You say that the enrollee say an in-network provider and they 
should be considered in-network. The Plan denied your request. The Plan says the Medicare rules have not 
been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Review of the file shows that codes 
S8301 and S1015 have a status code of I. Medicare guidance says status code - Not valid for Medicare 
purposes. Medicare uses another code for reporting of and payment for these services.  
 
Per Medicare CPT code(s): A4550 and 99072 has a status code of 'B' on the CMS Physician Relative Value 
File and is always bundled into payment for other services not specified and no separate payment is made. 
 
Per Medicare CPT code(s): A4556, A4557 and A4649. A4649 which has a status indicator of 'P' on the CMS 
Physician Relative Value File and is always bundled into payment for other services not specified and no 
separate payment is made. Therefore, we decided that the Plan does not have to pay for the services (CPT 
code(s): A4649, A4550, A4556, A4557, S8301, S1015, 99072) provided to the enrollee on March 17, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for four emergency department visits in which 
you received four doses of the rabies vaccine from May 11, 2021, to May 25, 2021. 
 
You asked the Plan to waive the copayment for the emergency room visits. You say that you feel the $90 
copayment for an emergency room visit is excessive. You were told to stop in to get the vaccine. You say you 
would understand if the service were billed as a regular office visit, but you only received the vaccination and 
then left. The Plan denied your request. The Plan says the cost-sharing was applied correctly. The Plan 
reviewed medical records submitted by the provider and determined that an evaluation and management 
service was provided on each date of service alongside the administration of the vaccine. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for Emergency Care.  
 
You have been asked to pay a total of $360 in copayments for the four emergency room visits ($90 ? 4 visits = 
$360). The services at issue fall within the Emergency Care benefit category. According to the Plan?s EOC, 
emergency care includes services that are needed to evaluate or stabilize an emergency medical condition. The 
medical records confirm a medical evaluation was conducted at each date of service. 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 four emergency department visits in which you received four doses of the rabies 
vaccine from May 11, 2021, to May 25, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a tertiary-level referral to an OB/GYN.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says that a tertiary level of care is not needed.
The Plan must follow Medicare rules. Medicare rules generally allow plans to restrict enrollees to using plan
providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan
says that, with few exceptions, you must use contract providers for care. Continuity of care must be ensured.
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 the referral. Our reviewer says that the
requested referral is considered medically reasonable and necessary in this case. Our physician reviewer found
you are sufficiently complex and have possible recurrence of cancer. It is in your best interests to continue care
with the long-term provider you have been seeing, especially in a case as complex as this one. It is
unreasonable to make you change providers. It is not good care.
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 referral have been met. Therefore, we decided that the Plan has to preapprove
a tertiary-level referral to an OB/GYN.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the x-ray services coded 71045 provided on July 4, 2021. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says that the claim is not payable as it is a duplicate. 
 
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. The documentation shows that the Plan is denying this claim due to it being a 
duplicate. No other explanation was provided. The documentation shows that more than one x-ray was 
provided for this date of service. The documentation does not support why this claim was a duplicate. The 
Medically Unlikely Edit (MUE) for CPT code 71045 is four (4). It appears from the limited documentation 
provided by the Plan that three x-rays were provided at various times on July 4, 2021. This number does not 
exceed the MUE for this code. The plan has not substantiated their denial. Therefore, we decided that the Plan 
has to pay for the x-ray services coded 71045 provided on July 4, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder Monitor test (CPT code 0013M), for the enrollee. 
 
You asked the Plan to pay for the service. You say that the service should be covered. The Plan denied your 
request. The Plan says the service is not covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. The rules say non-coverage 
reaffirmed for CPT codes 0012M and 0013M for CxBladder. Therefore, we decided that the Plan does not have 
to pay for CxBladder Monitor test (CPT code 0013M), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device (E0673 and E0675). 
 
You asked the Plan to pay for intermittent limb compression device. You say that the items were medically 
necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered by 
Medicare for the prevention of deep vein thrombosis during or after surgery. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device 
(E0673 and E0675).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve consultation with an in-network hand surgeon.
You asked the Plan to pre-approve the hand surgery consultation. You say that you broke your finger and had this confirmed by x-ray on August 6 with your PCP. You were told that the referral to a specialist would be handled but you were referred to a specialist that indicated they were out of network and could not see you. You were then approved to see multiple other specialists including a gynecologist, despite being a male, but were denied consultation with the hand specialist. You are asking to be approved to see the specialist you need for your condition. The Plan denied your request. The Plan says that you need to have your care coordinated by your PCP and it was noted that you were referred to an orthopedic surgeon. It is noted that your PCP has not provided an order to see the requested hand specialist.
The Plan must follow Medicare rules. Medicare rules say that MA plans must provide and arrange specialty care for medically necessary services. There must be written policies to ensure timely access to these services. The file shows that you have been attempting to be seen by a hand specialist since early August. You claim that a number of incorrect referrals were approved but none for a hand specialist. The Plan has indicated that you were referred to a Dr. but no evidence of this was provided and an online search shows this provider mostly works with knee/hip conditions. Based on the totality of the evidence presented, we find that the Plan has not enacted policies to ensure timely access to care. We find that the denial for consultation with a hand surgeon is not supported. Therefore, we decided that the Plan has to pre-approve consultation with an in-network hand surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network visit services provided to the enrollee on July 
6, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. 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 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 visit services provided to the 
enrollee on July 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on March 3, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary, and this 
is a covered benefit. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the laboratory work provided on March 3, 2021, by an OON 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the frames and lenses provided on June 24, 2021. 
 
You asked the Plan to pay more for the frames and lenses. You say that you chose a more expensive frame than 
you would have without the allowance. You say that you are disappointed in the denial of services that you 
were told is available. The Plan denied your request. The Plan says the total $250 allowance has been paid. 
 
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 up to $250 every calendar year for eyewear. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the frames and lenses have not been met. Specifically, the Plan paid the full $250 allowance 
toward the purchase of the glasses. You are responsible for the remaining cost over the $250 allowance. 
Therefore, we decided that the Plan does not have to pay more for the frames and lenses provided on June 24, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the autonomic nervous system function testing provided on 
June 23, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the autonomic nervous system function testing. You say that the service was 
medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the autonomic nervous system function testing 
provided on June 23, 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 the hospital discharge services (99239) provided on April 28, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that only one hospital discharge day management 
service is payable per patient per hospital stay.  
 
We looked at the file and Medicare rules. The records show that code 99239 was processed and paid by the 
Plan for the date of service in question. Per Medicare rules, code 99239 is only payable once per patient per 
hospital stay. This means that the requested services exceed the benefit limit and are not payable. 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 the hospital discharge services (99239) provided on April 28, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the pelvic ultrasound you had on July 28, 
2021. 
 
You asked the Plan to waive the copayment for the pelvic ultrasound. You say that you believe you should only 
be responsible for the office visit copayment and not any additional cost sharing. The Plan denied your request. 
The Plan says you were charged this copayment 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 $30 
copayment for outpatient diagnostic procedures and tests.  
 
You have been asked to pay a $30 copayment for the pelvic ultrasound. The pelvic ultrasound falls within the 
outpatient diagnostic procedures and tests benefit category. Plans are permitted to charge separate cost sharing 
if you receive diagnostic test services during an office visit. 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 the pelvic ultrasound you had on July 28, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the deductible applied for the laboratory services provided on May 26, 2020.
You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the deductible has been applied correctly to the services provided.
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. The Plan has not supplied sufficient information, such as an Explanation of Benefits Statement, to show that the enrollee had not met their deductible prior to the date of service at issue. Therefore, we decided that the Plan has to waive the deductible applied for the laboratory services provided on May 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx testing rendered on May 28, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
  
We looked at the file and Medicare rules. There is no documentation to support that the testing was necessary 
for the enrollee. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne Liquid CDx 
testing rendered on May 28, 2021.
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 on 
April 28, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. 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 must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 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 on April 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for outpatient hammertoe surgery provided on 
February 26, 2021, and follow-up x-rays provided on March 11, 2021, and April 1, 2021, in outpatient hospital 
settings. 
 
You asked the Plan to reduce the copayment for outpatient surgery and x-rays. You say that you were told by 
the provider that they are a free-standing surgery center and should therefore only have a copayment of $100 
for an ambulatory surgical center.  You also say that you feel you should not be charged for the follow-up appointments. The Plan denied your 
request. The Plan says the cost-sharing was applied correctly. The Plan confirmed that the provider bills as a 
hospital and not as an ambulatory surgical center. 
 
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 $275 
copayment for Outpatient Surgery, including services provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers. Your contract with the Plan also clearly says that you must pay a $25 copayment 
for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a total of $325 in copayments for outpatient surgery and x-rays ($275 hammertoe 
surgery copayment + 2 x-rays at $25 each = $325). These services fall within the Outpatient Surgery, including 
services provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers and Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit categories, respectively. 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 outpatient hammertoe surgery provided on February 26, 2021, and follow-up x-
rays provided on March 11, 2021, and April 1, 2021, in outpatient hospital settings.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99072) provided on January 7, 2021, and 
January 19, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee 
Schedule indicates that payment for covered services are always bundled into payment for other services not 
specified.  
 
We looked at the file and Medicare rules. Code 99072 is assigned a status indicator of ?B? under the Physician 
Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for 
other services. No separate payment can be made for this service. 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 the services (99072) provided on January 7, 2021, and January 19, 2021.