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

 
We decided that the Plan does not have to pay for a follow up visit provided on February 23, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a follow up visit. You say that this provider, being a trauma surgeon, does not get 
to pick and choose his patients or the insurance that they have. The Plan denied your request. The Plan says the 
member's plan excludes coverage for this out-of-network service.  
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 follow up visit provided on February 23, 2022, 
by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for speech therapy telehealth services 
provided from January 4, 2022, to March 22, 2022. 
 
You asked the Plan to waive the copayments for the speech therapy. You say that you were not aware of any 
copayments for the services. 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 $20 
copayment for each rehabilitation service.  
 
The file shows you had 21 telehealth visits for speech therapy from January 4, 2022, to March 22, 2022. You 
have been asked to pay a $20 copayment for each visit for the speech therapy, for a total of $420 ($20 
copayment x 21 visit = $420). The speech therapy falls within the Outpatient Rehabilitation Services 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 speech therapy telehealth services provided 
from January 4, 2022, to March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 1, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary and it 
is the facility's obligation to get authorization. The Plan denied your request. The Plan says unauthorized, non-
plan 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. 
 
Neither the provider in this case nor the facility where the services occurred is 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 medical 
services provided on February 1, 2022 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 provided to the enrollee on September 
30, 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 you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
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. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided to the enrollee on September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided to the enrollee on February 7, 
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 Current Procedural Terminology (CPT) code 83789-59 (1 unit) remains not supported 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
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. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for laboratory testing provided to the enrollee on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) provided by the out-of-network 
(OON) provider on September 21, 2021. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the items are not payable as they were rendered by 
an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, you must obtain hearing aids from a Plan provider. 
The Plan contract says that hearing aids are part of a covered benefit through the Plan provider and are not 
considered covered benefits by other providers. The hearing aids in this case were rendered by an out-of-
network provider. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) 
provided by the out-of-network (OON) provider on September 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist office visit and 
electrocardiogram (EKG) provided on October 15, 2021. We also decided that the Plan does not have to waive 
the copayments and coinsurance for a cardiovascular stress test, a nuclear stress test, and a technetium injection 
provided on October 21, 2021. 
 
You asked the Plan to waive the copayments and coinsurance for the office visit, EKG, stress tests, and 
injection. You say that it is your understanding that the pre-approval letters you received implied the services would be covered in full. The Plan denied your request. The Plan says the correct copayments and coinsurance 
were applied. 
 
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 services obtained from a specialist. 
 
Your contract with the Plan also clearly says that you must pay a $20 copayment for non-radiological 
diagnostic services, including EKG's and stress tests, a $110 copayment for radiological diagnostic services, 
including nuclear stress tests, and a 20% coinsurance for medical supplies, including chemical agents used in 
certain diagnostic procedures. 
 
You have been asked to pay a $35 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to 
pay $14.27 for the EKG, which is less than the $20 copayment, as well as a $20 copayment for the stress test. 
You have also been asked to pay a $110 copayment for the nuclear stress test, as well as $120 for the injection, 
which is 20% of the allowed amount ($600 allowed amount x 20% coinsurance = $120). The stress tests and 
injection fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. 
The total for both visits is $299.27. 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 a specialist office 
visit and electrocardiogram (EKG) provided on October 15, 2021. We also decided that the Plan does not have 
to waive the copayments and coinsurance for a cardiovascular stress test, a nuclear stress test, and a technetium 
injection provided on October 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical studies have not proven that this service is helpful for treatment. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing provided to the enrollee on February 16, 2022. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says that in addition to single gene testing, panels that include the FANCC genes are 
statutorily excluded service. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically 
necessary. 
 
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 the testing. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered a standard of care. 
The National Comprehensive Care Network (NCCN) NSCLC Guidelines Panel strongly advises broader 
molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be 
available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular 
profiling is a key component of the improvement of care of patients with NSCLC.  Testing of lung cancer 
specimens for these alterations is important for identification of potentially efficacious targeted therapies, as 
well as avoidance of therapies unlikely to provide clinical benefit. FoundationOne is one of the more common 
panels utilized. The service was reasonable and medically necessary.  
 
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 testing have been met. Therefore, we decided that the Plan has to pay for 
laboratory testing provided to the enrollee on February 16, 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 surgical services provided to the enrollee on September 27, 
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 the denied codes remain 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 the denied codes is  
CPT 22830: 
 
Exploration of spinal fusion 
 
CPT 22849: 
 
Reinsertion of spinal fixation device 
 CPT 22850: 
 
Removal of posterior nonsegmental instrumentation (eg, Harrington rod) 
 
CPT 63042: 
 
Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, 
foraminotomy and/or excision of herniated intervertebral disc, re-exploration, single interspace; lumbar 
 
CPT 63710: 
 
Dural graft, spinal 
 
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 not supported by the medical records. Our reviewer found that in terms of CPT 22830, the 
operative report describes exploration of spinal fusion during another procedure performed at same level. In 
this case, per Medicare guidelines, the exploration is included in the primary procedure and would not be 
reported separately. In terms of CPT 22849, and CPT 22850, the operative report describes reinsertion of spinal 
fixation device, removal of posterior segmentation and a posterior segmental instrumentation. In this case, the 
reinsertion and removal procedure would be inclusive to the instrumentation procedure, as the removal would 
be performed in order to complete the instrumentation. CPT 63042 was incorrectly reported. This bilateral 
surgical procedure would be billed with 1 unit with modifier 50. In terms of CPT 63710, the operative report 
describes dural graft performed for closure. Per the operative report "Nushield membrane was placed over the 
exposed dura and adhesion barrier." In this case, CPT 63710 would be inclusive to CPT 63042. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on September 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that you cannot afford this expense. You said that you do 
not think it is fair that Medicare does not cover this. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot 
orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital observation care provided from 
November 23, 2021, to November 24, 2021. 
 
You asked the Plan to waive the copayment for the observation care. You say that you were not moved to a 
room and should not be considered an inpatient. 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 $275 
copayment per visit for hospital observation services.  
 
The file shows that the charges were only for observation care, and not inpatient. Therefore, you have been 
asked to pay a $275 copayment for the observation care. The observation care falls within the Outpatient 
Hospital Observation 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 hospital 
observation care provided from November 23, 2021, to November 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Continuous positive airway pressure 
(CPAP) device on December 21, 2021. 
 
You asked the Plan to waive the coinsurance for CPAP device. You say that you sent the equipment back after 
having it for 2 days. The equipment did not work because your hand strength was too weak due to your arthritis 
condition and the water compartment didnt work, it would splash out all over the place. The old CPAP 
machine had a better design. The Plan denied your request. The Plan says the cost-sharing you are being 
charged is correct. 
 
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 per Medicare-covered item. Covered items include, but are not limited to: wheelchairs, crutches, 
powered mattress systems, diabetic supplies, hospital beds ordered by a provider for use in the home, IV 
infusion pumps, speech generating devices, oxygen equipment, nebulizers, and walkers. The provider billed in 
the amount of $350. $350 x 20% = $70. The total cost-sharing amount is $70.   
You have been asked to pay a 20% coinsurance for CPAP device. CPAP device falls within the Durable 
medical equipment (DME) and 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 Continuous positive airway pressure (CPAP) device on December 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair you purchased on February 10, 2022. 
 
You asked the Plan to pay for the wheelchair. You say that your son purchased this wheelchair from a vendor 
in St. Thomas, and they did not take any insurance. The Plan denied your request. The Plan says the provider 
from whom you received this wheelchair is not eligible to participate in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that DMEPOS providers must enroll in Medicare.  In 
addition, your Evidence of Coverage says that if you go to a provider who is not eligible to participate in 
Medicare, you will be responsible for the full cost of the services you receive. In this case, you used a vendor 
who has not enrolled in Medicare and is not an eligible provider. Based on this information, we decided that 
Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pay for the wheelchair you purchased on February 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a duplex scan (ultrasound) of lower 
extremity arteries provided on February 3, 2022. 
 
You asked the Plan to waive the coinsurance for the ultrasound. You say that the copayment should be waived 
due to your COVID-19 diagnosis. 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 an 18% 
coinsurance for advanced imaging services, including ultrasounds.  
 
You have been asked to pay $19.14, which is 18% of the allowed amount for the ultrasound ($106.31 allowed 
amount x 18% coinsurance = $19.14). The ultrasound 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 a 
duplex scan (ultrasound) of lower extremity arteries provided on February 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound of the arm and leg arteries 
you had on December 17, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you do not think you should have 
to pay this amount because the house call practitioner's machine picked up an incorrect abnormal reading.  You 
said that you did not need the ultrasound so you should not have to pay. The Plan denied your request. The Plan 
says you were charged this copayment correctly. The Plan says that because the allowed amount for this 
service ($126.38) is less than your copayment obligation, you are responsible for the full allowed 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 $160 
copayment for radiological diagnostic services.  
 
You have been asked to pay a $160 copayment for the ultrasound. The ultrasound falls within the radiological 
diagnostic services benefit category. This copayment applies regardless of the reason for the service or the 
outcome of the 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 the ultrasound of the arm and leg 
arteries you had on December 17, 2021.