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

 
We decided that the Plan does not have to pay for the office visit (99202) provided on February 15, 2021. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is not an established relationship between the 
enrollee and ordering physician. 
 
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 the office visit (99202) provided on 
February 15, 2021. have been met. Specifically, the documentation submitted does not include sufficient 
clinical information. Additionally, there is no evidence of an established relationship between the enrollee and 
ordering physician. Therefore, we decided that the Plan does not have to pay for the office visit (99202) 
provided on February 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy with polyp removal 
provided on November 23, 2021. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you were not billed for your 
previous colonoscopy, and this charge is 25% of your monthly income. The Plan denied your request. The Plan 
says the copayment amount 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 $280 
copayment for diagnostic colonoscopy at an ambulatory surgical center.  
 
 You have been asked to pay $280 copayment for colonoscopy. Colonoscopy 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 colonoscopy with polyp removal provided on 
November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on September 24, 2021. 
 
You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says there is no 
coverage if hearing aids, or related services are received from an out-of-network provider. The hearing benefit 
is not covered if the services are not registered in advance. 
 
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. The Plan pays for 
hearing aids only when ordered through the Plans hearing provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not ordered through the 
Plans hearing provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids 
have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids 
provided on September 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the male vacuum erection system (L7900), provided on 
September 23, 2021. 
 
You asked the Plan to pay for the male vacuum erection system. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured.  Therefore, we decided that the Plan does not have to pay for the male vacuum erection system (L7900), 
provided on September 23, 2021.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the testing described by codes 87150, 87801, and U0004. We decided 
that the Plan does not have to pay for the testing described by 87486.  
 
You asked the Plan to pay for the testing described by codes 87150, 87801, and U0004. You say that the 
documentation submitted supports the rendered testing. The Plan says that three of these codes are not 
appealable, and code 87486 was correctly denied due to a lack of the NCCI modifier. 
 
We decided that the Plan has to pay for the testing described by codes 87150, 87801, and U0004.  
 
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. 
 
These codes were denied on September 9, 2021, for requested information not being received. That such 
information was received as an appeal request would not exempt the codes from an appeal determination. Since 
the Plan forfeited the opportunity to provide a valid denial rationale, we find that the denial is not substantiated. 
Therefore, we decided that the Plan has to pay for the testing described by codes 87150, 87801, and U0004.  
 
We also decided that the Plan does not have to pay for the testing described by 87486. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 87486 is a Colum 2 code in relation to both 87150 and 878801. No NCCI modifier was reported in order 
to bypass the edit. Based on this information, we find that the Medicare billings rules for this service have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing described by 87486. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
January 21, 2021, to January 23, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. 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 $225 
copayment each day for days 1-5 for an inpatient hospital stay. The Plan contract also says that there is no 
charge for additional days after day 5. 
 
 You have been asked to pay a total of $450, which is a $225 copayment each day for a two-day inpatient 
hospital stay ($225 copayment x 2 days = $450). There is no copayment for the day of discharge. An inpatient 
hospital stay falls within the Inpatient Hospital Care 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 an inpatient hospital stay provided from January 21, 2021, to January 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on September 7, 2021, 
and November 8, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee has been a client since 2018. The 
Plan denied your request. The Plan says this provider type may not bill this service. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The records show that outpatient mental health services were provided by a 
counselor. This type of provider is not eligible to participate in Medicare. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the psychotherapy services provided on September 7, 2021, and 
November 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the abdomen (76700) provided on October 
29, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76700. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
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 76700 
is a column II code to column I code 93976. 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 the ultrasound of the abdomen (76700) provided on October 29, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on November 30, 
2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you have never been charged in the 
past and disagree with the charges. The Plan denied your request. The Plan says the claims were processed 
correctly, and you are being charged the correct 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 $0 
copayment for diagnostic bone mass measurements, diagnostic colonoscopies, and diagnostic mammograms 
and a $50 copayment for all other services. 
 You received an ultrasound of the breast on November 30, 2021.  An ultrasound of the breast is considered a 
diagnostic service. Therefore, you are responsible to pay the $50 copayment.  
 
You have been asked to pay a $50 copayment for an ultrasound. An 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 
copayment for an ultrasound provided on November 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy provided 
on July 30, 2021. 
 
You asked the Plan to waive the copayment for an esophagogastroduodenoscopy. You say that the provider 
submitted the claim incorrectly. You also say that you should not have a copayment applied to these 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 $200 
copayment for outpatient surgery at an ambulatory surgical center.  
 
An esophagogastroduodenoscopy is not considered a preventive service. It is considered a surgical service. 
You have been asked to pay a $200 copayment for an esophagogastroduodenoscopy. An esophagogastroduodenoscopy 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 an esophagogastroduodenoscopy provided on July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on March 22, 2021. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is not an established relationship between the 
enrollee and ordering physician. 
 
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 the office visit (99202) provided on 
March 22, 2021. have been met. Specifically, the documentation submitted does not include sufficient clinical 
information. Additionally, there is no evidence of an established relationship between the enrollee and ordering 
physician. Therefore, we decided that the Plan does not have to pay for the office visit (99202) provided on 
March 22, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the urinary pathogen testing by nucleic acid provided on June 15, 2021, 
billed with 13 units of code 87798. 
 
You asked the Plan to pay for the urinary pathogen testing by nucleic acid. You say that this is medically 
necessary testing. The Plan denied your request. The Plan says that these services are not authorized because 
molecular genetic testing is not a Medicare benefit for the diagnoses as listed on the claim and are done for 
screening purposes.  
 
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 provided a cogent denial rationale for the testing at issue. We 
find that denial based on this being a noncovered genetic screening test is not supported. This testing was 
performed for the diagnosis of urinary tract infection (UTI). Though it is noted by the Plan that the ordering 
provider's office stated that they do not order genetic testing, this is not genetic testing per se. This is testing to 
detect the genetic material of urinary pathogens. The lab report shows results for the billed number of 
pathogens, and this testing cannot reasonably be considered screening when performed in the presence of 
suspected UTI. As there is no supported denial rationale for these services, we find that the Plan's decision is 
not substantiated. Therefore, we decided that the Plan has to pay for the urinary pathogen testing by nucleic 
acid provided on June 15, 2021, billed with 13 units of code 87798.  
 
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 physical therapy services provided by a physical therapy 
assistant on September 23, 2021. 
 
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contract 
providers at the preferred provider rate when services are not available from preferred providers in the service 
area. You say that in-network benefits should be honored, and the claim processed for payment. The Plan 
denied your request. The Plan says the code is not appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist.  
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on October 29, 2021. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says this service is 
covered once every 12 months. You received an eye refraction on March 5, 2021, which is within the 12-month 
limit. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 
these services 1 every year. 
 
We looked at the file and the Plan's rules. The file shows that you received an eye refraction on March 5, 2021, 
which is within the 12-month limit. Based on this information, we decided that the Plan's rules for coverage of 
an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye 
refraction provided on October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided on September 
18, 2021. 
 
You asked the Plan to waive the copayment for specialist services. You say that you disagree with the charges 
because you were not aware that you were admitted under observation and thought you were inpatient. The 
Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the 
correct 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 $40 
copayment for specialist visits. 
 
The medical records show that you received specialist services on September 18, 2021. Therefore, you are 
responsible to pay the $40 copayment.   
 
 You have been asked to pay a $40 copayment for specialist services. Specialist services fall within the 
physician/practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for specialist services provided on September 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for Aveeno Moisturizing Lotion purchased on 
December 21, 2021. 
 
You asked the Plan to reimburse you for Aveeno Moisturizing Lotion. The Plan denied your request. The Plan 
says per the members benefit plan and the Pick Your Perks program; the Aveeno Moisturizing Lotion is 
not eligible for reimbursement. Moisturizing lotion must contain aloe to be eligible for reimbursement. The 
Aveeno Moisturizing Lotion purchased by the member did not contain aloe. 
 
The Plan contract offers a supplemental Pick Your Perks program benefit. The benefit says over-the-counter 
items must be included on the Plans allowed items list. 
 
We looked at the file and the Plans rules. The file shows that over-the-counter items must be included on the 
Plans allowed items list. Therefore, we decided that the Plan does not have to reimburse you for Aveeno 
Moisturizing Lotion purchased on December 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transportation (A0428, A0425) 
provided on November 10, 2020 
 
You asked the Plan to pay for the ambulance transport. You say that these claims were initially filed in a timely 
manner with no response from the insurance company. You included a screenshot to show the original 
submission date. The Plan denied your request. The Plan says this claim was received more than one year after 
the date of service. The documentation provided is not sufficient to prove timely filing as the payer listed is not 
the Plan, and the document is from the providers billing system. There is no evidence that this claim was 
received by the Plan in a timely manner, or that the provider was given notice that the claim was received. 
 
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 ambulance transport was not filed until December 14, 2021. 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 non-emergent ambulance transportation 
(A0428, A0425) provided on November 10, 2020