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

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 8, 2021. 
 
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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on June 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits, an x-ray examination of the 
chest, an x-ray examination of the knee, a magnetic resonance imaging (MRI) of any joint of lower extremity 
provided from August 20, 2021, to December 21, 2021. 
 
You asked the Plan to waive the copayment for office visits, an x-ray examination of the chest, an x-ray 
examination of the knee, a magnetic resonance imaging (MRI) of any joint of lower extremity. You say that the 
magnetic resonance imaging (MRI) shows a tear in the meniscus. You also say that it is not a strain, or sprain, 
or pulled muscle, this is a tear. The Plan denied your request. The Plan says you were 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 $5 
copayment for each Medicare-covered visit with a primary care physician (PCP). Your contract with the Plan 
also clearly says that enrollees must pay a $35 copayment per day, per provider, for Medicare-covered x-ray 
services. Your contract with the Plan also says that enrollees must pay a $225 copayment per day, per provider, 
for Medicare-covered diagnostic radiology services. 
 
You have been asked to pay a $5 copayment for 4 office visits. Office visits fall within the 
physician/practitioner services, including doctor's office visits benefit category. You have also been asked to 
pay a $35 copayment for an x-ray examination of the chest. You have also been asked to pay a $35 copayment 
for an x-ray examination of the knee. X-ray examinations of the chest and x-ray examinations of the knee, fall 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. You have also 
been asked to pay a $225 copayment for a magnetic resonance imaging (MRI) of any joint of lower extremity. 
A magnetic resonance imaging (MRI) of any joint of lower extremity falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category 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 office visits, an x-ray examination of the chest, an x-ray examination of the knee, a magnetic 
resonance imaging (MRI) of any joint of lower extremity provided from August 20, 2021, to December 21, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on November 22, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that this provider is not responsible to 
obtain authorization, and the assisted living facility is responsible to obtain prior authorization for all of their 
patients. The Plan denied your request. The Plan says this provider is out-of-network with the Plan, and 
authorization was not obtained prior to the 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 a domiciliary or rest home visit provided on 
November 22, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and a biopsy of the nail provided on August 
23, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and a biopsy of the nail. You say that you expected the service to 
be covered. The Plan denied your request. The Plan says the member does not have out-of-network benefits 
and the member did not have an authorization on file. 
 
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 an office visit and a biopsy of the nail provided on 
August 23, 2021, 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 an office visit, x-ray, and 
methylprednisolone injection (99214, 73562, J1030) provided on October 27, 2021. 
 
You asked the Plan to waive the copayment for the office visit, x-ray, and methylprednisolone injection. You 
say that the services should be covered as you disagree with the charges. The Plan denied your request. The 
Plan says the cost-sharing applied correctly based on the services provided. 
 
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 and a $75 copayment for Physician/Practitioner services, including doctors office visits and a 20% 
coinsurance for Medicare Part B prescription drugs  
You have been asked to pay a $40 copayment for the office visit, a $75 copayment for the x-rays, and a 20% 
coinsurance for the methylprednisolone injection (allowed is $11.25 x 20% = $2.25). 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 office visit, x-ray, and methylprednisolone injection (99214, 73562, J1030) 
provided on October 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy visit provided by a 
participating provider on December 16, 2021. 
 
You asked the Plan to waive the copayment for the physical therapy visit. You say that you are appealing this 
claim. The Plan denied your request. The Plan says you have been asked to pay 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 $40 
copayment for Medicare-covered physical therapy (in-person or virtual) visits.  
 
 You have been asked to pay a $40 copayment for the physical therapy visit. The physical therapy visit 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 copayment 
for the physical therapy visit provided by a participating provider on December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for professional services for allergen immunotherapy not 
including provision of allergenic extracts; single injection provided on June 4, 2021, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for professional services for allergen immunotherapy not including provision of 
allergenic extracts; single injection. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says the rendering provider is a non-participating provider and there is no referring 
provider involved in these services. The Plan also says that they did not authorize any services for this provider 
or this facility. 
 
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 professional services for allergen immunotherapy 
not including provision of allergenic extracts; single injection provided on June 4, 2021, 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 radiation therapy services provided on 
January 9, 2022. 
 
You asked the Plan to waive the copayment for radiation therapy services. You say that you feel you should not 
pay, and you were told in 2021 that you did not have any copayments. The Plan denied your request. The Plan 
says you were 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% 
coinsurance for radiation therapy at a primary care provider's (PCP) office, a specialist's office, or a stand-alone 
radiology center.  
 
You have been asked to pay a 20% coinsurance for radiation therapy services. Radiation therapy services fall 
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 radiation therapy services provided on January 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on December 7, 2021. 
 
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 71045 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 71045 (chest x-ray) and 74022 (complete acute abdomen 
series x-ray). Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 
74022. Code 71045 was not billed with an appropriate modifier to allow for separate payment. Therefore, we 
decided that the Plan does not have to pay for the chest x-ray rendered on December 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 14, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you have submitted documentation to prove 
that services were rendered due to medical necessity. The Plan denied your request. The Plan says after review, 
it was determined that there are no records of a prior authorization being obtained from the member's primary 
care physician (PCP) prior to services being on October 14, 2021. The Plan also says that the referring/ordering 
provider is out-of-network with the Plan. 
 
 
 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 on October 14, 2021, 
by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided by a 
network facility on December 4, 2021. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be 
responsibility for the copayment because no services were received. The Plan denied your request. The Plan 
says you have been asked to pay 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 $90 
copayment for Medicare-covered emergency room visits.  
 
 You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls 
within the Emergency care benefit category. The record shows you received oxygen which is considered a 
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 emergency room visit provided by a 
network facility on December 4, 2021. 
  
Your complaint about the poor customer service and lack of cleanliness is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an oncology specialist telehealth visit 
provided on January 27, 2022. 
 
You asked the Plan to reduce the copayment for a specialist telehealth visit. You say that you were told your 
telehealth visit with your oncologist would be a $5 copayment. 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 $30 
copayment for an in-network specialist telemedicine visit.  
 
You have been asked to pay a $30 copayment for a specialist telehealth visit. A specialist telehealth visit 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 reduce the copayment for an oncology specialist telehealth visit provided on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on October 15, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that this provider was not responsible to 
obtain authorization, and the assisted living facility is responsible to obtain prior authorization for all of their 
patients. The Plan denied your request. The Plan says this provider is out-of-network with the Plan, and 
authorization was not obtained prior to the 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 a domiciliary or rest home visit provided on 
October 15, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the AlloSure/CareDx testing (81479) provided on May 24, 
2021. 
 
You asked the Plan to pay for the AlloSure/CareDx testing. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says this claim was not submitted with the 
correct POS code. 
 
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 AlloSure/CareDx testing 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 the AlloSure/CareDx testing (81479) provided on May 24, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for professional services for allergen immunotherapy not 
including provision of allergenic extracts; single injection provided on July 21, 2021, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for professional services for allergen immunotherapy not including provision of 
allergenic extracts; single injection. You say that you originally saw the patient on August 19, 2020, to 
establish care and have allergy testing that day. You also say that when resulted, the patient was advised to start 
allergy immunotherapy. The Plan denied your request. The Plan says the rendering provider is a non-participating provider and there is no referring provider involved in these services. The Plan also says that they 
did not authorize any services for this provider. 
 
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 professional services for allergen immunotherapy 
not including provision of allergenic extracts; single injection provided on July 21, 2021, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology (solid organ), DNA, comprehensive genomic 
profiling provided on December 16, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for oncology (solid organ), DNA, comprehensive genomic profiling. You say that 
this denial is a violation of the Plan's contract with the Centers of Medicare and Medicaid Services (CMS), 
because all Medicare Advantage Organizations must cover services covered by original Medicare. The Plan 
denied your request. The Plan says the services are not authorized because this provider is a non-network 
provider who does not work with the Plan, and the member was referred by a provider who also does not work 
with the Plan. The Plan also says that the member's primary care physician did not refer for 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 oncology (solid organ), DNA, comprehensive 
genomic profiling provided on December 16, 2021, by an out-of-network (OON) provider.