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

 
We decided that the Plan does not have to pay for physician's services provided on April 19, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says the criteria for 
out-of-network coverage were not met. 
 
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 physician's services provided on April 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient surgery provided on February 18, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient surgery. You say that you are requesting a reconsideration on the 
outpatient surgery denial. You say that you were unaware the provider was considered out-of-network. The 
Plan denied your request. The Plan says an authorization was not obtained prior to 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 an outpatient surgery provided on February 18, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 22, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the denial because, based on 
the medical history of abstinence from substance, the frequency criteria had been met. The Plan denied your 
request. The Plan says an authorization was not obtained prior to 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 laboratory services provided on November 22, 
2021, 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 eye refraction provided on June 8, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you were not advised that this was not a covered 
benefit. The Plan denied your request. The Plan says an eye refraction is not a covered benefit. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the 
Plan does not have to pay for an eye refraction provided on June 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (0037U) provided on June 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service should be covered. The Plan denied 
your request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 the lab services (0037U) provided 
on June 24, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the services (Q0513) provided on February 28, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this code is not 
payable. 
 
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 rules also say that Medicare will only pay for one of the following for covered inhalation drugs 
regardless of the number of drugs dispensed, the number of shipments, or the number of pharmacies used by 
the beneficiary during that time period - an initial dispensing fee (G0333), a 30-day dispensing fee (Q0513), or 
a 90-day dispensing fee (Q0514). 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request.  The Plan has not provided documentation showing that the DME MAC does not 
price code Q0513. This code is payable per the DME contractor. Therefore, we decided that the Plan has to pay 
for the services (Q0513) provided on February 28, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on May 12, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that post-operative services are included in the global 
surgical package.  
 
We looked at the file and Medicare rules. Procedure codes 11750-T2-59 and 11750-T7-59 were related to and 
billed within 10 days of minor surgical procedure 11750-59-T6 and 11750-59-T1 billed on May 5, 2022. 
Payment for these services is included in the global surgical package. Therefore, we decided that the Plan does 
not have to pay for the surgical services rendered on May 12, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an at home OTC Covid test provided on May 22, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an at home OTC Covid test. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says Covid-19 tests are only covered 
when medically necessary and ordered by a physician. 
 
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 at home OTC Covid test provided on May 22, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the patient lift and manual wheelchair purchased 
November 4, 2021, to March 26, 2022. 
 
You asked the Plan to reimburse you for the patient lift and manual wheelchair. You say that you had COVID-
19 in October 2021 during which you fell and had to call EMS to get you up. You have used the lift twice since 
then for the falls and the wheelchair helps you get around the house without the fear of falling. The Plan denied 
your request. The Plan says services was rendered by a provider that does not participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the patient lift and manual 
wheelchair purchased November 4, 2021, to March 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Synvisc injection you received on 
August 2, 2022. 
 
You asked the Plan to waive the coinsurance for the Synvisc injection. You say that you did not know there 
would be a separate charge for the medication.  You were under the assumption that the drug would be 
included as part of the procedure. 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 Part B drugs.  
 
You have been asked to pay 20% coinsurance for the Synvisc injection. This item/service falls within the Part 
B drugs benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Synvisc injection you 
received on August 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service May 26, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83789 is bundled into payment for code G0480. 
 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 83789 
is a column II code to column I code G0480. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 83789 billed for date of service May 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DME provided from April 15, 2022, to April 25, 2022. 
 
You asked the Plan to pay for DME. You say that you are appealing the denial for a CPAP device and supplies 
that were purchased from an out-of-network provider. You say that you were told you would be reimbursed for 
50% but claim was denied due to no authorization. The Plan denied your request. The Plan says this DME was 
purchased from a non-Medicare assigned provider. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program.  
 
We looked at the file and Medicare rules. There is no evidence of a request for authorization for these supplies 
and if the rendering DME provider does not accept Medicare, the supplies are not covered. Based on this 
information, we decided that Medicare rules for coverage of DME have not been met. Therefore, we decided 
that the Plan does not have to pay for DME provided from April 15, 2022, to April 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service should be covered. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
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 sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for surgical radiation therapy provided on 
November 8, 2021, to November 17, 2021. 
 
You asked the Plan to waive the coinsurance for surgical radiation therapy. You say that you cannot afford the 
copayment. 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 outpatient diagnostic tests and therapeutic services and supplies. The allowed amounts of 
surgical radiation therapy total $8,151.52, resulting in a coinsurance amount of $1,630.31. 
 
You have been asked to pay 20% coinsurance for surgical radiation therapy. 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 coinsurance for surgical radiation therapy provided on November 8, 2021, to November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial preventive physical examination (G0402) provided 
on May 19, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service was medically 
necessary. The Plan denied your request. The Plan says there is a more appropriate code to describe the service 
in this case. 
 
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 G0402 is initial preventive physical examination; face-to-
face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment. 
 
We find that CPT code G0402 is not supported in the medical record. Specifically, the file shows that the 
enrollee was seen for a subsequent annual wellness visit. The record also shows that the enrollee has been 
enrolled in a Medicare Advantage plan for more than 12 months. Based on this information, we decided that Medicare rules for coverage of the evaluation and management service have not been met. Therefore, we 
decided that the Plan does not have to pay for the initial preventive physical examination (G0402) provided on 
May 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0037U) provided on March 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
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 sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (0037U) provided on March 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service June 7, 2022. 
 
You asked the Plan to pay for procedure code 93042. You say that the provider is entitled to separate payment 
of this code. The Plan denied your request. The Plan says payment for code 93042 is bundled into payment for 
code 12011. 
 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 93042 
is a column II code to column I code 12011. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93042 billed for date of service June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on April 18, 2022, by an out-of-
network (OON provider. 
 
You asked the Plan to pay for physician 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 for OON care have not been 
met. 
 
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 physician services provided on April 18, 2022, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physician's services for reconstruction of eyelid provided on 
July 20, 2022. 
 
You asked the Plan to pay for physician's services. You say that on this date of service you went back to the 
physician that did your eyelid surgery to remove the sutures from your left eyelid. The Plan denied your 
request. The Plan says that the billed service is not payable when performed in the providers office. 
 
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 has not provided us with a rule to support the denial. 
Therefore, we decided that the Plan has to pay for physician's services for reconstruction of eyelid provided on 
July 20, 2022.  
 
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 waive the copayment for vision services provided on July 7, 2022. 
 
You asked the Plan to waive the copayment for vision services. You say that you should not have to pay a 
copayment. 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 $30 
copayment for in-network vision services.  
 
You have been asked to pay a $30 copayment for vision services. This item/service falls within the in-network 
vision 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 vision services provided on 
July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy service (90832) provided on June 14, 
2022. 
 
You asked the Plan to pay for the psychotherapy service. You say that the service should be paid. The Plan 
denied your request. The Plan says there was no documentation of contact with the attending or primary care 
physician provided. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy service have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy service 
(90832) provided on June 14, 2022.