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

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on December 9, 
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 there is no necessity for an out-of-network 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 surgical services provided to the enrollee on 
December 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
November 10, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that the enrollee should only pay 
one copayment because both ambulance trips were related to one hospital visit. The Plan denied your request. 
The Plan says the copayment amount the enrollee is 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $265 copayment per date of service for ground ambulance services, regardless of the number of trips. 
This ambulance transportation occurred on a separate date of service, so a separate copayment applies to this 
claim. 
 
The enrollee has been asked to pay $265 copayment for ambulance transport. Ambulance transport falls within 
the Ambulance Services benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan.  This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
November 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on December 23, 
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 an appropriate modifier was not billed. 
 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 70450 
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on December 23, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a blood glucose test provided to the enrollee on November 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 that the provider is not covered for this service and is not eligible for reimbursement. 
 
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 substantiated their denial. The denied code - 82962 (Glucose, 
blood by glucose monitoring device(s) cleared by the FDA specifically for home use) is a coverable code by 
Medicare, and the plan has not stated clearly why the code was denied. Therefore, we decided that the Plan has 
to pay for a blood glucose test provided to the enrollee on November 30, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the speech therapy provided on June 8, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the speech therapy. You say that this claim was partially paid. The Plan denied 
your request. The Plan says the services were provided out-of-network and were not approved in advance. 
 
  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 speech therapy provided on June 8, 2021, by 
an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second annual eye exam provided on December 9, 2021. 
 
You asked the Plan to pay for a second annual eye exam. You say that you needed to have an eye exam for a 
new prescription for filtered eyeglasses. The Plan denied your request. The Plan says the benefit limit has been 
exceeded. 
 
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 one annually. 
 
We looked at the file and the Plan's rules. The file shows that you have exceeded the Plan vision benefit for one 
routine eye examination annually. Therefore, we decided that the Plan does not have to pay for a second annual 
eye exam provided on December 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 26, 
2021. 
 
You asked the Plan to pay for the services. You say that  The Plan denied your request. The Plan says it is not 
appropriate to report unspecified, or left and right diagnosis codes when a more specific (e.g. bilateral) code is 
available 
 
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 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 the services were denied because two 
or more diagnosis codes associated to it are mismatched per the ICD-10-CM Official Guidelines for Coding 
and Reporting. Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, 
right or is bilateral. It is not appropriate to report unspecified, or left and right diagnosis codes when a more 
specific (e.g. bilateral) code is available; therefore the reported service has been denied. The review has 
determined that the records do not support G0483 in this case. It was not reported with the most appropriate 
and accurate diagnosis code. 
 
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 drug testing services provided to the enrollee on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 billed for date of service December 3, 
2021. 
 You asked the Plan to pay for procedure code 99152. You say that you have provided medical records to 
support payment of this code. The Plan denied your request. The Plan says payment for code 99152 is bundled 
into payment for code 77263. 
 
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 99152 
is a column II code to column I code 77263. 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 99152 billed for date of service December 3, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for surgical debridements provided from 
January 26, 2021, to October 29, 2021. 
 
You asked the Plan to waive the copayments for outpatient surgery visits. You say that you received the same 
services in 2020 but were not charged. The Plan denied your request. The Plan says the copayment amounts 
you are being charged are 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 $350 
copayment per visit for in-network outpatient surgery at an outpatient hospital. For each visit, you have been 
asked to pay the allowed amount of the claim because this is less than the $350 copayment for in-network 
outpatient surgery.  The allowed amounts of these claims total $172.77, resulting in a copayment amount of $172.77. 
 
You have been asked to pay less than $350 copayment for each outpatient surgery visit. Outpatient surgery 
visits fall 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 copayments for surgical 
debridements provided from January 26, 2021, to October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service December 
27, 2021. 
 You asked the Plan to pay for procedure code 70480. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70480 is bundled into payment for 
code 70450. 
 
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 70480 
is a column II code to column I code 70450. 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 70480 billed for date of service December 27, 
2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services you received from a 
Licensed Alcohol and Drug Counselor from November 23, 2021, to December 21, 2021. 
 
You asked the Plan to pay for the outpatient mental health services. You say that you would like to appeal these 
claim denials. The Plan denied your request. The Plan says the provider you saw is not a Medicare-eligible 
provider. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers outpatient mental health 
services only when provided by one of the following recognized provider types: physicians, clinical 
psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, physician assistants, 
certified nurse-midwives, independently practicing psychologists, and certified registered nurse anesthetists. 
The provider from whom you received the services in dispute is not one of these provider types.   
 
 
 
 Licensed Alcohol and Drug Counselors are not a recognized provider type in order to receive Medicare 
payment for outpatient mental health services. Therefore, we decided that the Plan does not have to pay for 
outpatient mental health services you received from a Licensed Alcohol and Drug Counselor from November 
23, 2021, to December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided to the enrollee on November 
12, 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 this is not a covered benefit when provided by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services provided to the enrollee on November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 
16, 2021. 
 
You asked the Plan to pay for . You say that this should be paid for. The Plan denied your request. The Plan 
says the denied code requires a valid allergy extract prescription and mixing log. 
 
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 95165 is "Professional services for the supervision of 
preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number 
of doses)." 
 
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 . Our reviewer says that the services at issue in this case were 
not supported by the medical records. Our reviewer found the documentation does not include mixing log and 
allergy extract prescription to verify testing, as well as units billed. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of have not been met. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided to the enrollee on September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair. 
 
You asked the Plan to pay for a shower chair. You say that you would not have purchased this if it was not 
covered. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a shower chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Lab work provided on October 4, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for Lab work. You say that you would like to request reconsideration for payment. 
The Plan denied your request. The Plan says the provider is out-of-network and it was determined these 
services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Lab work provided on October 4, 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 the various services received from June 15, 2021, to October 
15, 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 there is no coverage for out-of-network benefits. 
 
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 various services received from June 15, 2021, 
to October 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement services provided on December 21, 2021, by an 
OON provider. 
 
You asked the Plan to pay for debridement services. You say that the treatment was medically necessary. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 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 debridement services provided on December 21, 
2021, by an OON provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a computed tomography (CT) scan provided on 
November 29, 2021. 
 
You asked the Plan to waive the copayment for CT scan. You say that you never had this scan performed and 
your doctor did not talk to you about results. The Plan denied your request. The Plan says that the copayment 
amount you are being charged is correct. 
 
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 rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. 
Your contract with the Plan says that enrollees must pay $200 copayment per provider, per date of service for 
CT scans. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. You say you never received this scan. The Plan did not submit any medical 
records to support that this service was performed as billed. The Plan attempted to obtain medical records, but 
none were provided. Without records, we cannot determine whether the CT scan at issue was performed on this 
date of service. Therefore, the Plan has not shown that its decision to cover this CT scan and ask you to pay a 
$200 copayment for it is correct or justified according to Medicare rules or your contract with the Plan. 
Therefore, we decided that the Plan has to waive the copayment for a computed tomography (CT) scan 
provided on November 29, 2021.  
 
 
 
 
 
 
 
 
 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 services provided on September 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 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 September 30, 2021.