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

 
We decided that the Plan does not have to waive the copayment for an eye and medical examination and 
evaluation provided on March 22, 2022. 
 
You asked the Plan to waive the copayment for an eye and medical examination and evaluation. You say that 
this was a routine eye exam. You also say that the provider did not do anything special. The Plan denied your 
request. The Plan says you were charged the 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 a medical eye exam.  
 
 
 
 
 
 You have been asked to pay a $30 copayment for an eye and medical examination and evaluation. An eye and 
medical examination and evaluation falls within the vision 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 eye and medical examination and evaluation provided on March 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 28, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 procedure code 70450 billed for date of service February 28, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder testing (code 0013M) provided on January 3, 
2022. 
 
You asked the Plan to pay for CxBladder testing. You say that this should be covered based on Medicare 
guidelines. The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that CxBladder test code 0013M is not covered by 
Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for 
CxBladder testing (code 0013M) provided on January 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for CPAP supplies provided on March 11, 
2022. 
 
You asked the Plan to waive the coinsurance for CPAP supplies. You say that you do not use the item and did 
not order it. You say that you are requesting a refund. The Plan denied your request. The Plan says you have 
been charged the correct coinsurance 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 durable medical equipment from an in-network provider.  
  You have been asked to pay $42.21, which is 20% coinsurance for the CPAP supplies.  
 
Service Allowed Amount In-Network Coinsurance Member Liability 
Airway Pressure Filter $11.82 20% $2.36 
Replacement Nasal Cushion $110.40 20% $22.08 
Tubing With Heating Element $35.46 20% $7.09 
Nasal Application Device $53.38 20% $10.68 
TOTAL   $42.21 
 
The CPAP supplies fall within the Durable Medical Equipment (DME) and Related Supplies benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for CPAP supplies provided on March 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for in-network lab work provided on November 
15, 2021. 
 
You asked the Plan to waive the deductible in-network lab work. You say that you should not have to pay this 
deductible as the service was in-network. The Plan denied your request. The Plan says the $48.52 deductible 
applied was correct. 
 
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 there is an in-network deductible of $300 which applies to in-network 
outpatient diagnostic tests.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is an in-network deductible of $300 which applies to outpatient diagnostic 
tests. This cost sharing is a contractual obligation that had not been met at the time in-network lab work was 
received on November 15, 2021. Therefore, we decided that the Plan does not have to waive the deductible for 
in-network lab work provided on November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the angiography and aortography services (75716 and 75625) 
provided on February 1, 2022. 
 
You asked the Plan to pay for codes 75716 and 75625. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the medical records do not support the services 
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, the CPT Code Manual definition of code 75716 is Angiography, extremity, bilateral, radiological 
supervision and interpretation. The definition of code 75625 is Aortography, abdominal, by serialography, 
radiological supervision and interpretation. 
 
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 codes 75716 and 75625. Our reviewer says that the medical records do not support the use of modifier 59 with code 75716 and do not support the billing of code 75625. 
Our reviewer found the operative report does not support that bilateral extremity angiography was a separate 
procedure from the intervention performed and reported with CPT 37184. For code 75625, the operative report 
does not include enough documentation to confirm per NCCI Policy Manual "The artery is percutaneously 
punctured with a needle and a guidewire is fed through the artery into the abdominal aorta. A catheter is 
threaded over the guidewire to the point of study and the guidewire is removed. Contrast medium is injected, 
and films are taken by serialography, producing a series of individual x-ray film".  The operative report 
documents "Access is upsized to a 5-french sheath and wire was used to position an Omniflush catheter in the 
abdominal aorta and aortogram was performed with the findings of patent aorta and bilateral iliac arteries". 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 75716 and 75625 have not been met. Therefore, we decided that the Plan 
does not have to pay for the angiography and aortography services (75716 and 75625) provided on February 1, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a fine needle aspiration biopsy performed 
on February 17, 2022. 
 
You asked the Plan to waive the copayment for the needle aspiration biopsy. You say that you were under the 
impression that this was only a diagnostic test. 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 $350 
copayment per visit for surgery or services at a hospital outpatient facility.  
 
You have been asked to pay a $350 copayment for the needle aspiration biopsy. The needle aspiration biopsy 
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 fine 
needle aspiration biopsy performed on February 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 10, 2022. 
 
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 January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam you had on April 29, 2022. 
 
You asked the Plan to pay for the exam. The Plan denied your request. The Plan says the benefit limit has been 
exhausted. 
 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 up to $75 per calendar year. 
 
We looked at the file and the Plan's rules. The records show that the Plan paid $75 toward your routine eye 
exam. You are responsible for any amount above the $75 benefit limit. Therefore, we decided that the Plan 
does not have to pay for the eye exam you had on April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth visit with a specialist provided 
on May 28, 2020. 
 
You asked the Plan to waive the copayment for telehealth visit with a specialist. You say that you only set up 
an appointment over the phone and shouldn't be charged a copayment for that. The Plan denied your request. 
The Plan says the copayment applied 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 $45 
copayment per visit to a specialist including telehealth appointments.  
 
You have been asked to pay $45 copayment for telehealth visit with a specialist. Telehealth visits with a 
specialist fall 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 telehealth visit with a specialist provided on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan of extracranial arteries; complete bilateral 
study provided on March 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a duplex scan of extracranial arteries; complete bilateral study. You say that you 
would like to request reconsideration of the denied claim. The Plan denied your request. The Plan says the 
provider is out-of-network, and it was determined these services can be received in-network. 
 
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 duplex scan of extracranial arteries; complete 
bilateral study provided on March 9, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advanced life support (A0433) and ground mileage 
(A0425) provided on January 9, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the Evidence of Benefits (EOB) was not received from the enrollee's primary 
insurance. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the ambulance services until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for the advanced life support (A0433) and ground mileage (A0425) 
provided on January 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for biopsy provided on December 13, 2021. 
 
You asked the Plan to waive the copayment for biopsy. You say that you were not aware ahead of time of the 
charge. The Plan denied your request. The Plan says the copayment applied 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 $375 
copayment per date of service at an outpatient hospital facility.  
 
 
 
 
 
 
 
 You have been asked to pay $310.95 which is less than the standard $375 copayment for biopsy. Biopsys 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 copayment for biopsy provided on 
December 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to 
the enrollee on October 21, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare Part B covers cardiovascular disease screening tests when ordered by the physician 
who is treating the beneficiary for the purpose of early detection of cardiovascular disease in individuals 
without apparent signs or symptoms of cardiovascular disease. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that genetic cardiovascular screening testing does not meet the definition of cardiovascular disease screening as outlined by 410.17 and thus is excluded from Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiac risk assessment genetic screening testing provided to the enrollee on October 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for ambulance transportation 
provided on February 14, 2022. 
 
You asked the Plan to waive or reduce the copayment for the ambulance transportation. You say that you feel 
that you paid too much compared to what insurance paid. 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 $290 
copayment per day for ambulance services.  
 
 
 
 
 
 You have been asked to pay a $290 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance 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 or reduce the 
copayment for ambulance transportation provided on February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 23, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 provided on August 23, 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 genetic testing provided on January 29, 2022 billed with 
codes 81275, 81210, 81206, and 81235. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 29, 2022 billed with codes 81275, 81210, 81206, and 81235.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76706 billed for date of service March 2, 
2022. 
 
You asked the Plan to pay for procedure code 76706. You say that the enrollee had multiple exams on this date. 
The Plan denied your request. The Plan says payment for code 76706 is bundled into payment for code 93976. 
 
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 76706 
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 procedure code 76706 billed for date of service March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit provided on February 24, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. You say that the services were 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 the outpatient visit provided on February 24, 2022, 
by an out-of-network (OON) provider.