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

 
We decided that the Plan does not have to waive the copayment for endoscopy provided on March 1, 2022. 
 
You asked the Plan to waive the copayment for endoscopy. You say that you were told the procedure would 
only be $15 copayment. 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 $300 
copayment per visit in an outpatient hospital.  
 
You have been asked to pay $300 copayment for endoscopy. Endoscopys 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 endoscopy provided on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive cardiovascular gene panel provided on 
February 17, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says procedures 
shall be reported with the most comprehensive code. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the gene panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the comprehensive cardiovascular gene panel provided on February 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a COVID-19 at-home test kit provided on  
January 30, 2022, and February 8, 2022. 
 
You asked the Plan to reimburse you for a COVID-19 at-home test kit. The Plan denied your request. The Plan 
says Medicare will not be eligible to be reimbursed through this initiative for tests purchased before  
April 4, 2022. 
 
The Plan must follow Medicare rules.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the COVID-19 at-home test kit have not been met. Therefore, we decided that the Plan does not 
have to reimburse you for a COVID-19 at-home test kit provided on January 30, 2022, and February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on  
February 9, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a COVID-19 at-home test kit provided on January 26, 2022. 
 
You asked the Plan to pay for a COVID-19 at-home test kit. You say that you were watching the news that said 
that the government would pay the insurance company for these tests. The Plan denied your request. The Plan 
says per CMS guidelines, Medicare coverage and payment began on April 4, 2022. 
 
The Plan must follow Medicare rules.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the COVID-19 at-home test kit have not been met. Therefore, we decided that the Plan does not 
have to pay for a COVID-19 at-home test kit provided on January 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 24, 2022. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says the testing is not separately 
reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary pharmacogenetics testing provided on 
February 11, 2022. 
 
You asked the Plan to pay for the testing services. You say that the treatment was medically necessary based on 
the enrollee's condition. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the testing panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the hereditary pharmacogenetics testing provided on February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 16, 2022, 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 authorization is 
required prior to an out-of-network visit. 
 
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 March 16, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services, outpatient radiology and lab services 
provided from January 4, 2022, to March 2, 2022. 
 
You asked the Plan to pay for physician services, outpatient radiology and lab services. The Plan denied your 
request. The Plan says your plan excludes coverage for this out-of-network service. 
 
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 
service at issue. We found no exception that would require the Plan to pay for these services.  
 
 
 
  
 
Therefore, we decided that the Plan does not have to pay for physician services, outpatient radiology and lab 
services provided from January 4, 2022, to March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213-25 billed for date of service October 
18, 2021. 
 
You asked the Plan to pay for procedure code 99213-25. You say that this code should be covered because the 
provider addressed multiple patient concerns during this visit. The Plan denied your request. The Plan says you 
billed an inappropriate number of units for this code. 
 
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 99213 is Established patient office or other outpatient 
visit, 20-29 minutes. 
 
We find that CPT code 99213 is not supported in the medical record. Specifically, according to the claim you 
submitted, you billed 13 separate units of code 99213.  This is not permissible as this is a 'once per day' code 
since it represents an established patient office visit.  The number of units billed is the sole reason for this 
denial- there was no argument by the Plan that the -25 modifier was not supported. Based on this information, 
we decided that Medicare rules for coverage of procedure code 99213-25 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99213-25 billed for date of service October 18, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a COVID-19 at-home test kit provided on  
January 15, 2022. 
 
You asked the Plan to reimburse you for a COVID-19 at-home test kit. You say that the United States 
administration said these tests were covered and you were not aware that it was for private insurance and not 
Medicare. The Plan denied your request. The Plan says although the Medicare coverage start date is effective 
April 1, 2022, the Plan made a business decision to start coverage as of February 1, 2022. 
 
The Plan must follow Medicare rules.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a COVID-19 at-home test kit have not been met. Therefore, we decided that the Plan does not have 
to reimburse you for a COVID-19 at-home test kit provided on January 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit (99335) provided on March 29, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the rest home visit. You say that an authorization should be on file as numerous 
consultations have been provided for the enrollee in this case. You also say that the services were provided to 
the enrollee in good faith. The Plan denied your request. The Plan says authorization was not obtained prior to 
the services being rendered to the enrollee. The Plan says that the services were not urgent or emergent in 
nature. The Plan also says the services were not directed by a plan 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 provider in this case is not a network provider with the Plan. 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 rest home visit (99335) provided on March 29, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services provided were medically necessary. 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 January 27, 2022, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a follow up located in a hospital, provided 
on February 18, 2022. 
 
You asked the Plan to waive the copayment for a follow up located in a hospital. You say that you should not 
have to pay this copayment. The Plan denied your request. The Plan says the copayment 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 a $750 deductible which applies to Physician/Practitioner services.  
 
The item or service you asked the Plan to waive the copayment for falls within the benefit category 
Physician/Practitioner services. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $750 deductible which applies to Physician/Practitioner services. Therefore, you are being billed for 
$37.76. This cost sharing is a contractual obligation that had not been met at the time a follow up located in a 
hospital was received on February 18, 2022. Therefore, we decided that the Plan does not have to waive the 
copayment for a follow up located in a hospital, provided on February 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of 
admission to a LTACH. The Plan denied your request. The Plan says after review of the enrollee's records it 
has been determined that they do not meet the criteria for LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with a urinary tract infection and 
sepsis with altered mental status requiring intravenous antibiotics and fluids and complicated by acute renal 
failure. The enrollee was started on tube feeds. Recent notes describe the enrollee as still lethargic with 
encephalopathy and without permanent feeding source. The enrollee is receiving appropriate care at the present 
setting. The enrollee does not require services at the LTACH that are not available at the acute care hospital 
where they are currently receiving care. 
  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that your lab does not have a contract with the dialysis 
facility for these services. The Plan denied your request. The Plan says these lab services are not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
lab services provided on January 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage 
have not been met because the requested service is experimental/investigational. 
 
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 pre-approve an Intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the Intracept procedure is considered an experimental/investigational procedure. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for thyroidectomy provided on March 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for thyroidectomy. You say that due to network insufficiency, the out-of-network 
provider was the only available assistant at the time of the procedure and rendered services specifically 
requested by the in-network primary physician and in-network facility. The Plan denied your request. The Plan 
says the services were rendered by a provider who is non-participating with the Plan network, and this provider 
specialty does not have the capacity to bill directly for the services rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for thyroidectomy provided on March 22, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that your lab does not have a contract with the dialysis 
facility for these lab services. The Plan denied your request. The Plan says these lab services are not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
lab services provided on January 25, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) and x-ray of humerus (73060) 
provided on December 30, 2020. 
 
You asked the Plan to pay for the physician services. You say that the GW modifier denotes that the treatment 
is not related. The Plan denied your request. The Plan says the enrollees claim would be covered under 
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the 
last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify 
the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the office visit (99214) and x-ray of humerus (73060) 
provided on December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the eye exam (92014) provided on March 
28, 2022. 
 
You asked the Plan to reduce the copayment for the eye exam. You say that nothing was done differently 
during this eye exam. You also say that they only checked your vision and checked for cataracts. The Plan 
denied your request. The Plan says additional services were rendered during your comprehensive eye exam. 
The Plan also says that per your Evidence of Coverage, if you receive services that address a medical condition 
during the same office visit, you pay a $50 specialist office visit copayment. 
 
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. 
 
 
 
 We looked at the file and the Plan's rules. The contract says you pay $15 for one annual routine eye exam. If 
you receive services that address a medical condition during the same office visit, you pay a $50 specialist 
office visit copayment. The record shows that you received additional services other than just a routine exam. 
Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. 
Therefore, we decided that the Plan does not have to reduce the copayment for the eye exam (92014) provided 
on March 28, 2022.