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

 
We decided that the Plan does not have to pay for the complete joint ultrasound rendered on August 11, 2021. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the complete joint ultrasound 
rendered on August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive pharmacogenetic testing provided on 
December 6, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services in question were clearly 
medically necessary as evidenced by the enclosed requisition form from the enrollee's treating physician. The 
Plan denied your request.  The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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. Additionally, the performance of multiple molecular tests regardless of whether the 
requisition lists the tests as a panel or individually, and completed on a single sample is considered to be a 
panel of tests and should be billed under a single CPT code to prevent stacking of codes. 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 comprehensive pharmacogenetic testing provided on December 6, 2021 by an out-of-
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (72170, 73030, 73552) provided on 
February 21, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not emergent or pre-authorized. There were network 
providers available. 
 
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 services 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 these services. Therefore, we decided 
that the Plan does not have to pay for radiology services (72170, 73030, 73552) provided on February 21, 2022 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth service provided on January 
11, 2022. 
 
You asked the Plan to waive the copayment for the telehealth service. You say that the enrollee received a 
copayment bill for $40 for an office visit. You say that the enrollee has never received a bill for something like 
this. The Plan denied your request. The Plan says the enrollee has been charged the correct copayment 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $40 copayment for telehealth services from an in-network specialist. Telehealth services include to 
diagnose, evaluate, or treat symptoms of a stroke, regardless of your location.  
 
 
 
 The enrollee has been asked to pay a $40 copayment for the telehealth service. The telehealth service falls 
within the Physician/Practitioner services, including doctor's office visits benefit category. This means that 
the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the telehealth service provided on January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services provided on January 
31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chronic care management services. You say that it was medically necessary 
to provide service to the enrollee and would like the claim reprocessed for payment. The Plan denied your 
request. The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 chronic care management services provided on 
January 31, 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 physical therapy services provided from 
December 2, 2021, to January 11, 2022. 
 
You asked the Plan to waive the copayment for physical therapy services. You say that your copayment should 
be $15 instead of $40. 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 $40 
copayment for in- network physical therapy services at an outpatient hospital.  
 
 
You have been asked to pay a total of $360 for physical therapy services. ($40/visit x 9 visits = $360). Physical 
therapy services fall within the Outpatient rehabilitation 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 physical therapy services provided from December 2, 2021, to January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (70450) provided November 27, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed has a bundled relationship with another code billed and 
is 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 CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. 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 radiology services (70450) provided November 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81206, 81235, 81292, 81301, 81321) provided 
September 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one HCPCS code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single panel. 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 (81206, 81235, 81292, 81301, 81321) provided 
September 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of HHA visits. 
 
You asked the Plan to pre-approve continuation of HHA visits. The Plan denied your request. The Plan says 
your personal care needs can be met with less complex services. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 continuation of HHA visits. Our 
reviewer says that continuation of HHA visits are not medically necessary. Our physician reviewer found that 
based on the medical records provided there is no documentation that the services meet the definition of home 
health aide services. The provided records do not document any acute or unstable medical conditions or 
changes in medication or treatment or change in functional status which would necessitate any further skilled 
home health aide visits beyond what have already been approved.  No medical notes from your treating physician are provided documenting a signed order or need for additional 
skilled home health aide services. There is no documentation that the home health aide services meet Medicare 
criteria for reasonable and necessary to the treatment of your illness or injury by the skilled professional staff. 
The provided records do not document any acute or unstable medical conditions or changes in medication or 
treatment or change in functional status which would necessitate any further skilled home health aide visits 
beyond what have already been approved. No medical notes from your treating physician are provided 
documenting a signed order or need for additional skilled home health aide services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of HHA visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of HHA visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for exercise equipment (A9300) provided on December 10, 
2021. 
 
You asked the Plan to pay for exercise equipment. You say that the service at issue should be covered because 
you do not want to go to the gym out of fear of contracting the COVID-19 virus. 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 exercise equipment is not covered because it is 
not primarily medical in nature.  
 
While exercise equipment may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for exercise equipment (A9300) provided on 
December 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (G0402, G0463) provided October 5, 
2021. 
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 codes G0402 and G0463 are not supported in the medical record. Specifically, multiple 
outpatient visits were billed on the same day without a required condition code (G0). Based on this 
information, we decided that Medicare rules for coverage of the outpatient services have not been met. 
Therefore, we decided that the Plan does not have to pay for outpatient services (G0402, G0463) provided 
October 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a nuclear stress test provided on February 
14, 2022. 
 
You asked the Plan to waive the deductible for a nuclear stress test. You say that you received a letter stating 
the stress test was approved, not stating anything about the cost being associated. You say that if you knew 
what the cost was you would not have had the test done. The Plan denied your request. The Plan says the 
deductible applied correctly. 
 
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 a nuclear stress test.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible which applies to a nuclear stress test. This cost sharing 
is a contractual obligation that had not been met at the time a nuclear stress test was received on February 14, 
2022. Therefore, we decided that the Plan does not have to waive the deductible for a nuclear stress test 
provided on February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88305) provided March 5, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 (88305) provided March 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the requested inpatient mental 
health care is medically necessary. The Plan denied your request. The Plan says the requested inpatient mental 
health care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care.  Our reviewer says that the requested inpatient mental health care is not medically necessary. Our physician 
reviewer found this enrollee did not require inpatient mental health treatment beyond the dates in question as he 
was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did 
not appear that active treatment was taking place beyond the date in question. It did not appear that the services 
for the dates in question were reasonably expected or medically necessary to improve the enrollees condition 
or for the purpose of diagnosis. I am unable to find an individualized treatment plan however the entire record 
is not present. It appears that the services were supervised and evaluated by a physician. Based upon review of 
the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health 
treatment facility beyond the date in question and the enrollee could have been treated in a lesser restrictive 
setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions 
and was not showing any behaviors or aggression, and was being cooperative and compliant while not showing 
any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care.
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 November 14, 
2021. 
 
You asked the Plan to pay for an X-ray of the chest. You say that you have provided records to support the 
service billed. 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 74022. 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 November 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on February 4, 2022. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says the services 
received were for a medical eye refraction for the diagnosis of Age-related nuclear cataract, bilateral. Eye 
refractions are only covered by your plan if performed by a participating provider and performed as a routine 
screening per your Evidence of Coverage. 
 
The Plan must follow Medicare rules. 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 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. Therefore, we decided 
that the Plan does not have to pay for an eye refraction provided on February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 21, 2021. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says this service was 
carried out by a chiropractor and per your Evidence of Coverage, only manual manipulation of the spine for the 
treatment of subluxation is covered by Medicare. 
 
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 an office visit provided on December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on January 6, 2022. 
 
You asked the Plan to pay for an eye refraction. You say that the refraction should be covered because it was in 
preparation for cataract surgery. The Plan denied your request. The Plan says Original Medicare doesn't cover 
routine eye exams (eye refractions) for eyeglasses/contacts. 
 
The Plan must follow Medicare rules. 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 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. Therefore, we decided 
that the Plan does not have to pay for an eye refraction provided on January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses provided on January 25, 2022. 
 
You asked the Plan to pay for contact lenses. The Plan denied your request. The Plan says you have exceeded 
the allowed Plan benefit for vision services. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services every two calendar years. 
 We looked at the file and the Plan's rules. The file shows that you received the eyewear benefit previously on 
January 9, 2021. Therefore, we decided that the Plan does not have to pay for contact lenses provided on 
January 25, 2022.