Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for diabetic supplies provided from 
September 2, 2021, to March 28, 2022. 
 
You asked the Plan to waive the coinsurance for diabetic supplies. You say that you haven't had a copay for 
these items before, and never saw a bill before now. You cannot afford this coinsurance amount. 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 20% 
coinsurance for durable medical equipment (DME) and other related supplies.  
 
$272.97 x 20% = $54.59 + $272.97 x 20% = $54.59 = $109.18 
$259.72 x 20% = $51.94 + $259.72 x 20% = $51.94 + $259.72 x 20% = $51.94 = $155.82 
 
$109.18 total + $155.82 total = $265. 
 You have been asked to pay a total coinsurance of $265 for diabetic supplies.  
This item/service falls within the durable medical equipment (DME) and other related 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 coinsurance for diabetic supplies provided from September 2, 
2021, to March 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for infectious agent detection by nucleic acid (DNA or RNA); 
Staphylococcus aureus, amplified probe technique provided to the enrollee on June 22, 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 that the billed code cannot be verified. 
 
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 87640 is "Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified 
probe technique." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the reviewed documentation indicates 
that Current Procedural Terminology (CPT) code 87640 (1 Unit) is supported. The documentation submitted 
does include a lab report or lab results for this test; therefore, the billed code can be verified. The review has 
determined that the records support that infectious agent detection by nucleic acid (DNA or RNA); 
Staphylococcus aureus, amplified probe technique was provided on the denied date of service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique 
provided to the enrollee on June 22, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) provided on June 23, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service was medically 
necessary. The Plan denied your request. The Plan says prior 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 provider in this case is not a network provider with the Plan. 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 the office visit (99215) provided on June 23, 2022, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (80061, 80053, 84439, 84436, 84443, 84480, 
84481, 85025 and 86376) provided on May 19, 2021. 
 
You asked the Plan to pay for the lab services. You say that you were not given the correct diagnosis. The Plan 
denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until June 29, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the lab services (80061, 80053, 84439, 84436, 84443, 84480, 84481, 85025 and 
86376) provided on May 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
May 9, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the provision of F1CDx to the enrollee 
meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria 
 
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 find that CPT code 0037U is not supported in the medical record. Specifically, the specimen 
was collected on July 14, 2021, received on April 29, 2022, and the date of service on the claim is May 9, 
2022. The next generation sequence testing (NGS) testing panel performed included testing for the FANCC 
gene. Testing for this gene is not a Medicare benefit and is statutorily excluded service. In addition to single 
gene testing, panels that include the FANCC gene are statutorily excluded service.  Based on this information, 
we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we 
decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided May 9, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gravity assisted traction device provided on April 14, 2022. 
 
You asked the Plan to pay for gravity assisted traction device. You say that your provider gave you a 
prescription for the inversion table for your back. You say that the Plan should cover 80%. The Plan denied 
your request. The Plan says they cannot pay for non-emergency services from a provider who does not 
participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for gravity assisted traction device provided 
on April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) and glycosylated hemoglobin test 
(83036) provided on June 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained. The Plan also says the services 
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 provider in this case is not a network provider with the Plan. 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 the office visit (99214) and glycosylated hemoglobin test (83036) provided on 
June 14, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation services received on June 16, 
2022. 
 
You asked the Plan to pay for the ambulance transportation services. You say that the enrollee is bedridden and 
has no other way to go anywhere except by ambulance. The Plan denied your request. The Plan says the 
services received are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for the ambulance transportation services received on 
June 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on January 13, 2022. 
 
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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 4, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the office visit rendered on January 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology of skin fungi and subsequent laboratory 
testing provided on February 11, 2022, and April 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you provide processing and diagnostic 
reporting to the referring provider and should be paid. The Plan denied your request. The Plan says the services 
were performed by an out-of-network provider without a prior authorization. The Plan also says that the 
referring podiatrist is out-of-network. 
 
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 surgical pathology of skin fungi and subsequent 
laboratory testing provided on February 11, 2022, and April 15, 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 70544 billed for date of service July 9, 2022. 
 
You asked the Plan to pay for procedure code 70544. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551. 
 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 70551. 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 July 9, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on September 9, 
2020, to February 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON outpatient mental health services. You say that you would like the Plan 
to consider a referral for this patient. The Plan denied your request. The Plan says unauthorized, out-of-network 
care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The provider 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. Therefore, we 
decided that the Plan does not have to pay for outpatient mental health services provided on September 9, 2020, 
to February 28, 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 services (88341, 88342, 88360, 88381) provided on 
January 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be billed as 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 code 88341, 88342, 88360, & 88381 is not supported in the medical record. Specifically, 
these services have a professional component / technical component indicator of 1. The services were 
performed in the outpatient hospital setting and were not billed with the required 26 modifier. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (88341, 88342, 88360, 88381) provided on January 
17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88360, 88341, 88381, 88342) provided on April 
21, 2022. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
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 code 88360, 88341, 88381 and 88342 is not supported in the medical record. Specifically, 
the codes billed have a professional component / technical component of 1. The service was billed with place 
of service 22, outpatient hospital. The codes were not billed with the required modifier 26. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (88360, 88341, 88381, 88342) provided on April 21, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nerve block provided on September 1, 
2022, and September 2, 2022. 
 
You asked the Plan to waive the copayment for a nerve block. You say that you never had a procedure, it was 
just an injection and an x-ray. 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 $350 
copayment for outpatient surgery, including services provided at hospital, outpatient facilities and ambulatory 
surgical centers. You had two procedures (these nerve blocks count as an outpatient procedure) each was $350, 
giving a total of $700 ($350 x 2 procedures = $700). 
 
You have been asked to pay a $700 total copayment for a nerve block. This item/service falls within the 
outpatient surgery, including services provided at hospital, outpatient facilities and ambulatory surgical centers 
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 nerve block provided on September 1, 2022, and 
September 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a pain management visit provided on 
October 19, 2021. 
 
You asked the Plan to waive the coinsurance for a pain management visit. You say that the provider didn't ask 
for consent to getting this done, therefore, you should not have to pay a coinsurance. 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 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this drug or item is $1,417.58, 
resulting in a coinsurance amount of $214.94, which is less than the 20% that is typically charged ($1,417.58 x 
20% = $214.94). 
 
You have been asked to pay a $214.94 coinsurance for a pain management visit. This item/service 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 a pain management visit provided on October 
19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 20900) provided to the 
enrollee on June 29, 2022. 
 
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 this was not reported correctly. 
 
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 20900 
is a column II code to column I code 27130 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for surgical services (procedure code 20900) provided to the enrollee on June 29, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry procedures (83789) billed for date of 
service June 7, 2022. 
 
You asked the Plan to pay for mass spectrometry. 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 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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of mass spectrometry have been met. 
Specifically, medical records from the referring provider to support the need for the services at issue are absent. The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for mass spectrometry procedures (83789) billed for 
date of service June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a high-strength lightweight wheelchair (K0004) billed for 
date of service May 12, 2021. 
 
You asked the Plan to pay for a high-strength lightweight wheelchair. You say that the service at issue was 
billed correctly. 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 suppliers must add a KX modifier to the code for 
the manual wheelchair base only if all of the coverage criteria have been met. 
 
We find that a high-strength lightweight wheelchair has been billed without the KX modifier. Based on this 
information, we decided that Medicare rules for coverage of a high-strength lightweight wheelchair have not been met. Therefore, we decided that the Plan does not have to pay for a high-strength lightweight wheelchair 
(K0004) billed for date of service May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for astigmatism-management laser surgery provided from April 
12, 2022, to May 25, 2022. 
 
You asked the Plan to pay for astigmatism-management laser surgery. You say that the services at issue were a 
medical necessity for you. The Plan denied your request. The Plan says the services at issue are not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that he use of radial keratotomy and/or keratoplasty 
for the purpose of refractive error compensation is considered a substitute or alternative to eye glasses or 
contact lenses, which are specifically excluded. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of astigmatism-management laser surgery have not been met. Specifically, ophthalmological laser 
surgery is not a covered benefit. Therefore, we decided that the Plan does not have to pay for astigmatism-
management laser surgery provided from April 12, 2022, to May 25, 2022.