Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided from September 28, 2021, to October 12, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
the enrollee had fallen, shattered their femur, and had reconstructive surgery. You also say that stretcher 
transport was required for the follow-up visits with the surgeon, and any other transportation would have 
damaged the reconstruction and necessitated a repeat hospitalization. The Plan denied your request. The Plan 
says the enrollee received transportation from their home to a physicians office, and from the physicians 
office, the enrollee was returned to their home. The Plan also says that these services denied correctly as non-
covered benefits. 
 
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 non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided from September 28, 2021, to October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 27, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service is medically necessary and should be 
paid. 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, for 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 lab 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 lab services provided on May 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a digital, binaural hearing aid (V5261) provided on June 22, 
2022. 
 
You asked the Plan to pay for a digital, binaural hearing aid (V5261). You say that you called and were told 
you could see the rendering provider. The Plan denied your request. The Plan says you must see a specific Plan 
provider to use this benefit. 
 
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 the hearing aids are purchased by a Plan provider.  
 
We looked at the file, and the Plan's rules. The record shows the hearing aids were not purchased by a 
participating Plan provider. Based on this information, we decided that the Plan's rules for coverage of a digital, 
binaural hearing aid (V5261) have not been met. Therefore, we decided that the Plan does not have to pay for a 
digital, binaural hearing aid (V5261) provided on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) and progressive lenses (V2781) provided 
on August 7, 2022, by an out-of-network (OON) provider. 
 You asked the Plan to pay for the frames and progressive lenses. You say that you would like this service 
covered. The Plan denied your request. The Plan says this service is not covered when provided OON without 
prior authorization. 
 
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 prior authorization is obtained before receiving OON services. 
 
We looked at the file and the Plan's rules. In this case the routine eyewear was obtained OON without first 
obtaining prior authorization. Based on this information, we decided that the Plan's rules for coverage of the 
frames and progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for 
the frames (V2020) and progressive lenses (V2781) provided on August 7, 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 copayment for the physical therapy (PT) services provided 
on June 21, 2022, to July 08, 2022. 
 
You asked the Plan to waive the copayment for the physical therapy (PT) services. You say that the services 
were not effective, and you would like to be reimbursed. 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 $160 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $160 copayment for the physical therapy (PT) services. This item/service 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. Per the EOC, there is a $40 copayment for outpatient rehabilitation services. 
The file shows 4 visits from June 21, 2022, to July 8, 2022, for a total of $160. Therefore, we decided that the Plan does not have to waive the copayment for the physical therapy (PT) services provided on June 21, 2022, to 
July 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on April 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the telehealth visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there are no out-of-network benefits for physician services. 
 
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 telehealth visit provided on April 18, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11045 billed for date of service April 1, 
2021. 
 
You asked the Plan to pay for procedure code 11045. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 11045 is bundled into payment for code 15734. 
 
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 11045 
is a column II code to column I code 15734. 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 11045 billed for date of service April 1, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapy visit provided on June 2, 2022, and on June 22, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a therapy visit. You say that you have seen this provider before, and it was 
covered. Why was it denied now? The Plan denied your request. The Plan says the provider became out of 
network during the year. 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 a therapy visit provided on June 2, 2022, and on 
June 22, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Durable medical equipment (DME) 
provided on July 30, 2021. 
 
You asked the Plan to waive the coinsurance for DME. You say that you are requesting reconsideration on the 
cost share that was applied. 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 20% 
coinsurance for in-network Durable medical equipment (DME) and related supplies.  
 
You have been asked to pay 20% coinsurance for DME. You are being asked to pay is $335.10 for the DME. 
The total amount you are being asked to pay is $67.02 ( $335.10 x 20% = $67.02). 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 Durable medical equipment (DME) provided on July 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on April 06, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says as a member of our plan, the enrollee must use network providers. If the enrollee 
receives unauthorized care from an out-of-network provider, we may deny coverage and the enrollee will be 
responsible for the entire cost. 
 
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 testing provided on April 06, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Telephone evaluation and management service (99442) 
provided on February 23, 2022. 
 
You asked the Plan to pay for the Telephone evaluation and management service. 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. 
 
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 99442 is Telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 11-20 minutes of medical discussion. 
 We find that CPT code 99442 is not supported in the medical record. Specifically, the documentation shows 
that the provider billed and was paid for an evaluation and management (E/M) service code, 99204 on February 
16, 2022. This is within the seven days allowed per the Telephone E/M services and thus is included in the 
previously billed E/M code. This means this code is not separately payable. Based on this information, we 
decided that Medicare rules for coverage of the Telephone evaluation and management service have not been 
met. Therefore, we decided that the Plan does not have to pay for the Telephone evaluation and management 
service (99442) provided on February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided from April 25, 2022, to June 13, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for offices visits. You say that you are requesting a review of the records to show 
medical necessity and reprocess the claim for payment. The Plan denied your request. The Plan says an 
authorization was not obtained prior to services rendered. 
 
  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 office visits provided from April 25, 2022, to June 
13, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing (G0483) provided on January 3, 2022. 
 
You asked the Plan to pay for procedure code G0483. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the records do not support the billing of 
code G0483. 
 
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 G0483 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the records support that 22 or 
more drug classes have been tested, including amphetamines, barbiturates, benzodiazepines, buprenorphine, 
skeletal muscle relaxants, fentanyls, gabapentin, ketamine, methadone, opiates, pregabalin, oxycodone, 
tramadol, sedative hypnotics, cannabinoids, stimulant (synthetic), cocaine, methylenedioxyamphetamines, 
alcohol biomarkers, heroin metabolite, alkaloids, and phencyclidine. Based on this information, we decided 
that Medicare rules for coverage of procedure code G0483 have been met. Therefore, we decided that the Plan 
has to pay for the drug testing (G0483) provided on January 3, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab examination provided on May 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab examination. You say that the beneficiary needed this treatment, 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 examination provided on May 27, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a gastroenterology visit provided on June 6, 
2022. 
 
You asked the Plan to waive the copayment for a gastroenterology visit. You say that you were in the ER, then 
you were admitted, and saw this provider. You feel you should not have to pay this copayment. 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 $40 
copayment for physician/practitioner services, including doctors office visits.  
 
You have been asked to pay a $40 copayment for a gastroenterology visit. This item/service falls within the 
physician/practitioner services, including doctors 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 a gastroenterology visit provided on June 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on May 10, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollees network primary care provider (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving you a 
"referral." 
 
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 testing provided on May 10, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management service (code 99309) 
provided on April 22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for code 99309. You say that these services were medically necessary and the 
patient's primary care provider would not give you a referral. 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 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 the evaluation and management service (code 
99309) provided on April 22, 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 from September 21, 2021, to 
September 27, 2021, by an out-of-network (OON) provider. 
 
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 a referral/authorization was not obtained prior to services being rendered. 
 
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 laboratory services provided from September 21, 
2021, to September 27, 2021, by an out-of-network (OON) provider.