Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit at an 
outpatient hospital facility provided on December 19, 2022, to December 30, 2022. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit at an outpatient hospital 
facility. You say that you requested a stand alone facility for physical therapy and your provider referred you to 
this location. 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 $25 
copayment for outpatient rehabilitation service. 
 
You have been asked to pay a $25 copayment for each physical therapy (PT) visit at an outpatient hospital 
facility. This item/service falls within the outpatient rehabilitation service 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. The total you owe is $75 for PT 
services provided at an outpatient hospital facility ($25 per visit x 3 visits = $75). Therefore, we decided that 
the Plan does not have to waive the copayment for each physical therapy (PT) visit at an outpatient hospital 
facility provided on December 19, 2022, to December 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided on December 13, 2022. 
 
You asked the Plan to pay for outpatient surgery. You say that you were unaware that the services were out of 
network. The Plan denied your request. The Plan says that 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for outpatient surgery 
provided on December 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visit and ultrasound 
provided on August 25, 2022. 
 
You asked the Plan to waive the cost share for the specialist office visit and ultrasound. You say that these 
services were provided as the result of a faulty test from a previous provider. 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 $35 
copayment for specialist office visits. Your contract with the Plan also clearly says that you must pay a $115 copayment for radiological diagnostic services, including ultrasounds. 
 
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services benefit category. You have also been asked to pay $79.11, which is less than the 
standard $115 copayment for the ultrasound. This item/service falls within the outpatient diagnostic tests and 
therapeutic services benefit category. You have been asked to pay a total of $114.11 ($35 copayment + $79.11 
copayment = $114.11). 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 cost share for the specialist office visit and 
ultrasound provided on August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on November 10, 2022. 
 
You asked the Plan to pay for injections. You say that you did not know your provider was no longer in-
network. The Plan denied your request. The Plan says that 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for injections provided on 
November 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the leg x-rays provided on October 26, 2022. 
 
You asked the Plan to pay for the leg x-rays. You say that the records provided support medical necessity. The 
Plan denied your request. The Plan says that 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the leg x-rays provided 
on October 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that you are requesting 
an additional 129 trips for dialysis. The Plan denied your request. The Plan says the benefit only allows for 48 
trips. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve the additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body tooth #29 (second 
stage implant surgery) (D6011), custom fabricated abutment  includes placement #29 (D6057), and implant 
supported porcelain/ceramic crown #29 (D6065). 
 
You asked the Plan to pre-approve the dental services represented by codes D6011, D6057 and D6058. You 
say that you are asking for approval for the dental services. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 27, 2023. 
Therefore, we decided that the Plan does not have to pre-approve surgical access to an implant body tooth #29 
(second stage implant surgery) (D6011), custom fabricated abutment  includes placement #29 (D6057), and 
implant supported porcelain/ceramic crown #29 (D6065).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on October 6, 2022 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
paramedics found your blood pressure was too high and recommended that you go to the hospital but you 
refused. You also say later that day your health had not improved so you called the paramedics and were 
transported to the hospital. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 6, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on October 6, 2022
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on December 06, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that this was medically necessary and should 
be covered. The Plan denied your request. The Plan says that 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
services provided on December 06, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on September 15, 2022. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you feel you are 
not liable for the PT copayment because you did not get the care you shouldve received. 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 $35 
copayment for outpatient rehabilitation service.  
You have been asked to pay a $35 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation service 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 each physical therapy (PT) visit provided on September 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 10, 2022, billed with 
codes 87481, 87500, 87640, 87651, 87653, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
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 
October 10, 2022, billed with codes 87481, 87500, 87640, 87651, 87653, and 87798.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positron emission tomography (PET) with concurrently 
acquired computed tomography (CT) of skull base to midthigh for attenuation correction and anatomical 
localization imaging provided on September 29, 2022, billed with procedure code 78815. 
 
You asked the Plan to pay for the PET image with CT. You say that the services were medically necessary The 
Plan denied your request. The Plan says the claim was not reported with an appropriate diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for PET scan services must be billed with 
the appropriate diagnosis codes to the A/B MAC (B). You can find this information in the Centers for Medicare 
and Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, 
Chapter 13, Section 16.1. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PET image with CT have not been met. Specifically, this claim has not been billed with an appropriate diagnosis code for the PET services billed. Therefore, we decided that the Plan does not have to 
pay for a positron emission tomography (PET) with concurrently acquired computed tomography (CT) of skull 
base to midthigh for attenuation correction and anatomical localization imaging provided on September 29, 
2022, billed with procedure code 78815.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye examination provided on December 19, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical eye examination. You say that you are appealing the denial. The 
Plan denied your request. The Plan says there was no referring provider, and the rendering provider was out-of-
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 did not pre-approve the 
medical eye examination. We found no exception that would require the Plan to pay for the medical eye 
examination. Therefore, we decided that the Plan does not have to pay for the medical eye examination 
provided on December 19, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the astigmatism-correct function of intraocular lens. 
 
You asked the Plan to pre-approve the astigmatism-correct function of intraocular lens. You say that if the Plan 
is willing to pay for a standard lens, they should pay for the upgrade to help your near and far sightedness. The 
Plan denied your request. The Plan says the service is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pre-approve the astigmatism-
correct function of intraocular lens.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral- periapical each additional radiographic image 
(D0230) provided on November 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says the enrollee already received the allowed frequency of intraoral  periapical first 
radiographic image (D0220) on the appealed claim so the rest is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 21, 2022. 
Therefore, we decided that the Plan does not have to pay for intraoral- periapical each additional radiographic 
image (D0230) provided on November 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 20, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on December 20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care visits provided on October 
12, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care visits. You say that the records attached support 
the services provided. The Plan denied your request. The Plan says that 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care visits provided on October 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two additional one-way trips. 
 
You asked the Plan to pre-approve additional one-way trips. You say that you were told that your plan would 
have unlimited rides, but only shows 10 one-way trips. The Plan denied your request. The Plan says the 
requested additional trips exceed the benefit allowance. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 10 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation as of March 9, 2023. 
Therefore, we decided that the Plan does not have to pre-approve two additional one-way trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, ultrasound, and cystoscopy provided from 
November 18, 2022, to December 29, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit, ultrasound, and cystoscopy. You say that the records do not 
indicate that the care provided was medically necessary. The Plan denied your request. The Plan says the 
records show that the care provided was medically necessary but could have been delayed until you followed 
up with an in-network urologist. 
 
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, ultrasound, and cystoscopy 
provided from November 18, 2022, to December 29, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0481 provided on June 7, 2022. 
 
You asked the Plan to pay for procedure code G0481. 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 G0481 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; 8-14 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the records show that more 
than 14 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of 
procedure code G0481 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0481 provided on June 7, 2022.