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

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on September 
17, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the copayment should be 
waived for the blood draw. The Plan denied your request. The Plan says the proper copayment was applied for 
the service. 
 
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 $10 
copayment for bloodwork processed at an independent lab.  
 
  You have been asked to pay a $10 copayment for the laboratory services. The laboratory services falls within 
the Outpatient hospital 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 the copayment for 
laboratory services provided on September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the counseling visit to discuss the need for lung cancer 
screening using a low dose computed tomography (CT) scan (G0296) rendered by the out-of-network (OON) 
provider on September 16, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the counseling visit to discuss the need for lung cancer screening using a low dose 
computed tomography (CT) scan (G0296) rendered by the out-of-network (OON) provider on September 16, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 5, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that services were provided to the enrollee and the claim 
should be paid. The Plan denied your request. The Plan says the rendering and referring providers are both out-
of-network providers and there was no approved 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 an office visit provided on November 5, 2021, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
May 8, 2021, to May 11, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you received a bill 
from the hospital for the coronavirus (COVID-19) treatment, and previously, for COVID-19 treatment, there 
was $0 copayment. You also say that you did not have a chance to get your COVID-19 vaccine and your 
COVID-19 treatment should be paid by the Plan. The Plan denied your request. The Plan says the $0 cost-
sharing for in-network and out-of-network COVID-19 treatment, including inpatient and outpatient treatment, 
was through March 31, 2021. The Plan also says that you were 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 $395 
copayment each day for days 1 to 4 for Medicare-covered hospital care.   
You have been asked to pay a $395 copayment each day for 3 days of inpatient hospital services, which is a 
total of $1,185 ($395 x 3 = $1,185). 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 inpatient hospital 
services provided from May 8, 2021, to May 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical preparation or creation of recipient site by 
excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar 
contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits (15004) 
rendered by the out-of-network (OON) provider on March 29, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the surgical preparation or creation of recipient site by excision of open wounds, burn 
eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, 
mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits (15004) rendered by the out-of-network 
(OON) provider on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and follow-up care to be rendered by the 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 
the requested services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a 
consultation and follow-up care to be rendered by the out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays provided on November 16, 2021, 
and November 29, 2021. 
 
You asked the Plan to waive the copayment for the x-rays. You say that the services should be covered as they 
were received at an urgent care facility. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided and they were provided in a hosptial and not an urgent care. 
 
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 $110 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $149.06 copayment for two x-rays, which is less than the standard $110 
copayment each. The x-rays fall 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 x-rays provided on November 
16, 2021, and November 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Otezla. 
 
You asked the Plan to pre-approve Otezla. 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 Otezla.  
 
Benefits for Otezla 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the review indicates that the complexity of the enrollee's nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (84590, 84446, 82306) provided August 16, 
2021. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says a correct claim is needed. 
 
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 CPT code 84590, 84446, & 82306 is not supported in the medical record. Specifically, the claim 
was submitted without a valid diagnosis code. A corrected claim was requested by the plan and none was 
received. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (84590, 84446, 82306) 
provided August 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on September 2, 2021. 
 
You asked the Plan to pay for physical therapy services. You say that the physical therapy services at issue 
were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have 
not been met. 
 The Plan must follow Medicare rules. Medicare rules say that when therapy services are billed as incident to a 
physician/NPP services the requirement for direct supervision by the physician/NPP and other incident to 
requirements must be met, even though the service is provided by a licensed therapist who may perform the 
services unsupervised in other settings. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, there is no evidence that the billing NPP 
was on site while the services were being rendered. Therefore, we decided that the Plan does not have to pay 
for physical therapy services provided on September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 15, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be 
covered as it was a follow up visit for a colonoscopy you previously received. The Plan denied your request. 
The Plan says the cost-sharing applied correctly based on the services provided, these services are not eligible 
to be considered a follow-up visit. 
 
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 the specialist office visit. the specialist office visit 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 waive the copayment for a specialist office visit provided on November 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a Laparoscopy (49650) provided on 
October 29, 2021. 
 
You asked the Plan to waive the deductible for the Laparoscopy. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the deductible applied correctly 
based on the services provided. 
 
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 $800 deductible which applies to Outpatient hospital services.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
hospital services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is an 
$800 deductible which applies to Outpatient hospital services. This cost sharing is a contractual obligation that 
had not been met at the time the Laparoscopy was received on October 29, 2021. Therefore, we decided that 
the Plan does not have to waive the deductible for a Laparoscopy (49650) provided on October 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tyrvaya. 
 
You asked the Plan to pre-approve Tyrvaya. 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 Tyrvaya.  
 
Benefits for Tyrvaya 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided September 3, 2021. 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the member's face-to-face service was rendered in a laboratory setting. 
Therefore, we decided that the Plan does not have to pay for lab services (81479) provided September 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network outpatient diagnostic services 
provided on October 20, 2021. 
 
You asked the Plan to waive the copayment for outpatient diagnostic services. You say that you should not be 
charged a $40 copayment because you did not see anyone in the office. The Plan denied your request. The Plan 
says the copayment charged was 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 a $40 
copayment for in-network outpatient diagnostic services.  
 
 You have been asked to pay a $40 copayment for outpatient diagnostic services. Outpatient diagnostic services 
falls within the in-network 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 in-network outpatient diagnostic services provided on 
October 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (80307) provided on October 22, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the non-urgent services are not authorized because the provider is a non-
network provider with the Plan, and the services provider is listed as the referring provider. The Plan also says 
that there is no necessity for an out-of-network provider, such as an urgent or emergency situation that has been 
documented. 
 
 
 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 drug testing (80307) provided on October 22, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional medical services (99053) provided on June 28, 
2021. 
 
You asked the Plan to pay for additional medical services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Per the Physician Fee Schedule, CPT code 99053 has a status indicator of B. This means that the payment for 
99053 is always bundled into the payment for another service or procedure. Based on this information, we 
decided that Medicare rules for coverage of additional medical services have not been met. Therefore, we 
decided that the Plan does not have to pay for additional medical services (99053) provided on June 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-ray of the chest (71045) provided on September 24, 
2021. 
 You asked the Plan to pay for an X-ray of the chest. You say that the service at issue was a necessity for the 
enrollee's care. The Plan denied your request. The Plan says rules for payment have not been met because the 
CPT code at issue is inclusive to another billed 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, we have confirmed that code 71045 
is a column II code to column I code 71046. 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 an X-ray of the chest (71045) provided on September 24, 2021.