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

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service April 8, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says procedure code 99053 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service April 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 10, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 laboratory services related to end-stage renal disease (ESRD) provided on June 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service April 1, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99053 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service April 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on June 20, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you thought this was included in the 
mammogram. 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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $88, which is less than the $100 copayment for ultrasound. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for ultrasound provided on June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for injection and specialist office visit provided 
on June 27, 2022. 
 
You asked the Plan to waive the cost share for injection and specialist office visit. You say that you are 
requesting reconsideration stating the services should be covered and were necessary. 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 20% 
coinsurance for Medicare Part B prescription drugs and $30 copayment for physician/practitioner services, 
including doctors office visits. The allowed amount of the injection total $875.40, resulting in a total 
coinsurance amount of $175.08. 
 You have been asked to pay 20% coinsurance for injection and $30 copayment for specialist office visit. This 
item/service falls within the Medicare Part B prescription drugs and physician/practitioner services, 
including doctors office visits benefit categories. 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 
injection and specialist office visit provided on June 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for drug test provided on April 25, 2022. 
 
You asked the Plan to waive the copayment for drug test. You say that you feel you should not have a cost 
share and your lab work should be covered under your benefits. 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 $40 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $6.30, which is less than the $40 copayment for drug test. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for drug test provided on April 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transportation (A0429) and 
ground mileage (A0425) provided on July 26, 2021. 
 
You asked the Plan to pay for the emergency ambulance transportation and ground mileage. You say that you 
would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says this claim 
was filed past the allowed 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency ambulance transportation and ground mileage was not filed 
until August 12, 2022. This means that more than one calendar year from the date of service had passed before 
a claim was filed. Therefore, we decided that the Plan does not have to pay for the emergency ambulance 
transportation (A0429) and ground mileage (A0425) provided on July 26, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service May 1, 
2022, to May 31, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like this claim to be reprocessed, 
and payment to be made. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service May 1, 2022, to May 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on May 03, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that you were 
never told you had this high copayment for this test. 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 $375 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $375 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan 
does not have to waive the copayment for a magnetic resonance imaging (MRI) provided on May 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.  
 
Benefits for Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance transportation services (A0427-EH, A0425-EH) provided 
on October 3, 2021. 
 
You asked the Plan to pay for ambulance transportation. You say that this was not a duplicate claim, and the 
enrollee was transported multiple times on this date. The Plan denied your request. The Plan says that this 
claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, the Plan has not included any proof of 
prior payment for these services in the case file. Based on this information, we decided that Medicare rules for 
coverage of ambulance transportation have been met. Therefore, we decided that the Plan has to pay for 
ambulance transportation services (A0427-EH, A0425-EH) provided on October 3, 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 chiropractic services (99203, 72100) provided on May 23, 
2022. 
 
You asked the Plan to pay for the chiropractic services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services at issue are not covered when provided by a 
chiropractor. The manual manipulation of the spine was covered. 
 
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 (99203, 72100) provided on May 23, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve genetic testing (81455). 
 
You asked the Plan to pre-approve genetic testing. You say that the requested genetic testing is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that rules for coverage have not been 
met. 
 
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. Specifically, the Plan's denial is based on the laboratory that is to provide the 
requested genetic testing services. There is no documentation in the case record to support that the provider the 
Plan has identified will be the provider of the requested services. It is the Plan's responsibility to substantiate its 
denial with evidence. In this case, the Plan's denial has not been substantiated, so we must find in your favor. 
Therefore, we decided that the Plan has to pre-approve genetic testing (81455).  
 
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 the Guidance UTI test provided March 31, 2022. 
 
You asked the Plan to pay for the Guidance UTI test. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this test was performed as a screening test and is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the Guidance UTI test, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the Guidance UTI test provided March 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided on February 10, 2022, by an 
out-of-network (OON) provider. 
 
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 were rendered by an out-of-network provider without 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 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 surgical services provided on February 10, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Magnetic Resonance Cholangiopancreatography 
(MRCP). 
 
You asked the Plan to pre-approve an MRCP. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRCP. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the record indicates that the 
enrollee has a family history of pancreatic cancer. The record provided indicates that the enrollee is 
asymptomatic and no genetic testing has been performed. The requested service is not medically necessary and 
reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time. The elements of the 
coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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 MRCP have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Magnetic Resonance Cholangiopancreatography (MRCP).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy visits. 
 
You asked the Plan to pre-approve 8 additional physical therapy visits. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 8 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found additional physical therapy visits are not medically necessary 
or reasonable based on the review of documentation by the therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 8 additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for gallbladder laparoscopy provided on April 
21, 2022. 
 
You asked the Plan to waive the copayment for gallbladder laparoscopy. You say that you were not told of this 
copayment before hand, and feel you should not have to pay it. 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 $350 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $350 copayment for gallbladder laparoscopy. This item/service falls within the 
outpatient hospital observation 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 
gallbladder laparoscopy provided on April 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 15 physical therapy visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve therapy visits. You say that you want your physical therapy to be done at 
your home. The Plan denied your request. The Plan says the requested services are available with in-network 
providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
15 physical therapy visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an office visit provided on May 07, 2022. 
 
You asked the Plan to reduce the copayment for an office visit. You say that you went to convenient care to see 
your primary provider who sometimes works there. You should not have a specilist copay. 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 $45 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for an office visit. This item/service falls within the 
Physician/Practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have 
to reduce the copayment for an office visit provided on May 07, 2022.