Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on April 14, 2022. 
 
  You asked the Plan to pay for an eye refraction (92015). You say that it was deemed necessary as part of your 
medical exam because of the headaches you were experiencing and the discovery of cataracts. The Plan denied 
your request. The Plan says this service is not covered. The Plan also said that eye refractions are only covered 
by the Plan if performed by a participating Plan provider and performed as a routine screening. 
 
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 these services when the eye refractions are done during a routine exam and when 
performed by a Plan routine vision care provider.. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover eye refractions during a routine exam 
and when performed by a Plan routine vision care provider. The record shows the charges were billed with a 
medical diagnosis for an eye refraction. Based on this information, we decided that the Plan's rules for coverage 
of an eye refraction (92015) have not been met. Therefore, we decided that the Plan does not have to pay for an 
eye refraction (92015) provided on April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for reproductive medicine procedures 
provided on March 31, 2022. 
 
You asked the Plan to waive the coinsurance for reproductive medicine procedures. You say that this has been 
reprocessed and you want the coinsurance removed. 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 50% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies. The Plan confirmed that the 
service that was billed does not match the service that was approved on the in-network waiver and 
authorization. 
 
You have been asked to pay a $250 coinsurance for reproductive medicine procedures. 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 coinsurance for reproductive medicine procedures provided on 
March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on March 30, 2022, 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 by a primary care provider (this is different than a referral) for an out-
of-network (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 
March 30, 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 computerized tomography (CT) scan on 
July 12, 2022. 
 
You asked the Plan to waive the copayment for a computerized tomography (CT) scan. You say that you would 
like to appeal the cost share. 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 a computerized tomography (CT) scan. The total allowed amount of the CT scan is $160.86, 
resulting in a coinsurance amount of $32.17. 
 
You have been asked to pay a 20% coinsurance for a computerized tomography (CT) scan. 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 a computerized tomography (CT) scan on July 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for a cardiovascular stress test provided on February 
23, 2022. 
 
You asked the Plan to waive the cost for a cardiovascular stress test. You say that you should not have to pay 
for this test. 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 $75 
copayment for outpatient diagnostic tests and therapeutic services and supplies, and a 20% coinsurance for 
Medicare Part B prescription drugs. The copayment for outpatient diagnostic tests and therapeutic services 
and supplies is typically $75, and you are being asked to pay $59.80. 
The allowed amount for Part B drug is $245.16 x 20% coinsurance = $49.03 ($59.80+$49.03=$108.83). 
 
You have been asked to pay a $108.83 for a cardiovascular stress test. This item/service falls within the 
Medicare Part B prescription drugs and 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 cost for a cardiovascular stress test provided on February 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested Intracept procedure is 
medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not medically necessary. Our physician reviewer found the 
Intracept procedure is experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a specialist office visit (99204) and an eye 
scan to detect disease (92134) provided on February 11, 2022. 
 
You asked the Plan to waive the coinsurance for a specialist office visit (99204) and an eye scan to detect 
disease (92134). You say that you would call the Plan to inquire about a physician for your visiting father, who 
directed you to the primary care physician (PCP) to get a referral. You also say that when you contacted the 
PCP for a referral, they referred you back to the Plan. 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 30% 
coinsurance for Medicare-covered exams to diagnose and treat diseases and conditions of the eye, including an 
annual glaucoma screening for people at risk. Your contract with the Plan also clearly says that enrollees must 
pay a 30% coinsurance for out-of-network Medicare-covered primary care doctor visit, specialist visit, and 
other health care professional service. 
 
You have been asked to pay $60.80 in coinsurance, which is 30% of the allowed amount for a specialist office 
visit (99204) and an eye scan to detect disease (92134) ($202.68 x 30% = $60.80). Eye scans to detect disease 
(92134) fall within the for Medicare-covered exams to diagnose and treat diseases and conditions of the eye, 
including an annual glaucoma screening for people at risk benefit category. A specialist office visit (99204) 
falls within the out-of-network Medicare-covered primary care doctor visit, specialist visit, and other health 
care professional service benefit category. The record shows that these services were covered, however, the 
enrollee has a cost share he is responsible for. 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 specialist 
office visit (99204) and an eye scan to detect disease (92134) provided on February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialty treatment to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve specialty treatment. You say that providers in-network don't treat your 
disorder and have bad reviews. The Plan denied your request. The Plan says there are providers within network 
who do treat your disorder. 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 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 
specialty treatment to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 27, 2022, billed with 
codes 81227, 81230, 81231, 81232, 81328, 81355, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 27, 2022, billed with codes 81227, 81230, 81231, 81232, 81328, 81355, 0031U, 0032U, and 0033U.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee injections with platelet rich plasma (PRP). 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is considered to be experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 injections. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that larger controlled studies comparing PRP with placebo and alternatives other than HA are 
needed to determine the efficacy of PRP for knee osteoarthritis. Further studies are also needed to determine 
the optimal protocol for delivering PRP. At the present time, the evidence is insufficient to determine the 
effects of PRP on health outcomes for oseoarthritis. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve knee injections with platelet rich plasma (PRP).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 7, 2022, billed with 
codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81306, 81328, 81335 and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says this test was not billed in 
accordance with Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 7, 2022, billed with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81306, 81328, 
81335 and 81355.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 5, 2021 billed with 
codes 81227, 81225, 81226, and 81401. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 5, 2021 billed with codes 81227, 81225, 81226, and 81401.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the hospital outpatient clinic visit (G0463) provided on October 13, 
2020. 
 
You asked the Plan to pay for the outpatient service. You say that this should be covered. The Plan denied your 
request. The Plan says that the claim was filed untimely. 
 
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. Specifically, the file shows that the Plan reprocessed the claim on March 2, 
2022. The file shows that the correct claim was received on June 2, 2022, less than 12-months after the 
submission. Additionally, the Plan has not indicated why the claim was reprocessed to deny. Therefore, we 
decided that the Plan has to pay for the hospital outpatient clinic visit (G0463) provided on October 13, 2020.  
 
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 rendered on April 9, 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 procedure code 99205 is not supported. 
 
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 99205 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and high 
level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on 
the date of the encounter. 
 
We find that CPT code 99205 is not supported in the medical record. Specifically, the file shows that the 
enrollee was seen by a physician of the same specialty in the same group on March 18, 2022; therefore, a new 
patient office visit does not apply. 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 office visit 
rendered on April 9, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a mammogram screening provided on August 2, 
2022. 
 
You asked the Plan to waive the copayment for a mammogram screening. You say that you are requesting a 
reconsideration because you believe this should have been a preventative service and the claim should be 
covered in full. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
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 enrollees must pay $0 copayment for covered screening mammograms. When 
services other than preventative are performed, the cost share associated with the other service will apply. 
 
The Plan says you must pay $250 copayment for a mammography screening. Based on the Plan contract, 
however, you cannot be asked to pay more than $0 copayment for a mammography screening. The Plan did not 
provide justification to prove the mammogram should be considered anything other than a preventative 
screening. Therefore, we decided that the Plan has to waive the copayment for a mammogram screening 
provided on August 2, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 14041 billed for date of service June 22, 2022. 
 
You asked the Plan to pay for code 14041. You say that this code is not included in the billing for procedure 
11642. The Plan denied your request. The Plan says this service was billed within the 10-day global period of 
code 11642. 
 
The Plan must follow Medicare rules. Medicare rules say that if a patient has a unrelated procedure during the 
postoperative period, the provider should append modifier 79.  In this case, it may be true that code 14041 is 
unrelated to code 11642.  However, you did not bill with the required 79 modifier to indicate that this code is 
separate and distinct during the postoperative period. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 14041 have not been met. Therefore, we decided that the Plan does not have to pay for code 
14041 billed for date of service June 22, 2022.