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

 
We decided that the Plan does not have to waive the coinsurance for radiation therapy provided on June 06, 
2023, to June 30, 2023. 
 
You asked the Plan to waive the coinsurance for radiation therapy. You say that you are requesting 
reconsideration for the denied claim. 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. 
 
You have been asked to pay 20% coinsurance for 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 radiation therapy provided on June 06, 2023, to June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mobile electrocardiogram (ECG) rendered on May 31, 
2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a mobile ECG. You say that you are appealing the denial. The Plan denied your 
request. The Plan says that their original decision to deny payment was correct. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a mobile ECG have been met. Despite 
the Plan's multiple attempts to obtain medical records and necessary information regarding the claim, they were 
never sent by the provider. Therefore, we decided that the Plan does not have to pay for a mobile ECG 
rendered on May 31, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a vision appointment provided on October 02, 2023. 
 
You asked the Plan to pay for a vision appointment. You say that you were unaware that this provider was out-
of-network. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a vision appointment 
provided on October 02, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84443, 82607, 82746, and 82306 for date of 
service March 29, 2023. 
 
You asked the Plan to pay for procedure codes 84443, 82607, 82746, and 82306. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
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 84443, 82607, 82746, and 82306 are not supported in the medical record. Specifically, 
the submitted medical records do not support that thyroid stimulating hormone was performed; therefore, code 
84443 is not supported. The submitted medical records do not support that cyanocobalamin was performed; 
therefore, code 82607 is not supported. The documentation does not support that folic acid; serum was 
performed; therefore, code 82746 is not supported. The medical records do not include documentation that code 82306 was performed. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 84443, 82607, 82746, and 82306 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 84443, 82607, 82746, and 82306 for date of service March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 10, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that this was a continuation of care. The Plan denied 
your request. The Plan says that their original decision to deny payment was correct.  
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 July 10, 2023, by an 
OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on March 08, 2023. 
 
You asked the Plan to pay for the radiology services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the radiology services 
provided on March 08, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic laboratory testing provided on March 31, 2023. 
 
You asked the Plan to pay for genetic laboratory testing. You say that this was medically necessary and should 
be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for genetic laboratory 
testing provided on March 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0480 billed for date of service July 7, 2023.  
 
You asked the Plan to pay for procedure code G0480. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code G0480 is bundled into payment for code 80307. 
 
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 G0480 
is a column two code to column one code 80307 with a modifier indicator of 0. The column two code is therefore not payable. 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 G0480 billed for date of service July 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99236 for date of service February 14, 2023. 
 
You asked the Plan to pay for procedure code 99236. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
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 99236 is hospital inpatient or observation care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires a 
medically appropriate history and/or examination and high level of medical decision making. When using total 
time on the date of the encounter for code selection, 85 minutes must be met or exceeded. 
 
 
 We find that CPT code 99236 is not supported in the medical record. Specifically, the documentation does not 
support that admission and discharge on the same date was provided. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99236 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99236 for date of service February 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient surgery provided on August 18, 2023. 
 
You asked the Plan to pay for the outpatient surgery. You say that you asking for the review of the medical 
documents. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the outpatient surgery 
provided on August 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a total hip replacement provided on 
October 26, 2022, to October 29, 2022. 
 
You asked the Plan to waive the coinsurance for a total hip replacement. You say that you were not advised of 
any additional cost for 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 40% 
coinsurance for out-of-network Medicare-covered outpatient surgery at an outpatient hospital facility. 
 
You have been asked to pay 40% coinsurance for a total hip replacement. This item/service falls within the out-of-network Medicare-covered outpatient surgery at an outpatient hospital facility 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. The total you owe $6,073.09 
($15,182.72 allowed amount x 40% = $6,073.09 rounded up). Therefore, we decided that the Plan does not 
have to waive the coinsurance for a total hip replacement provided on October 26, 2022, to October 29, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96372 for date of service May 21, 2023. 
 
You asked the Plan to pay for procedure code 96372. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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. 
 
In this case, the CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection 
(specify substance or drug); subcutaneous or intramuscular. 
 
We find that CPT code 96372 is not supported in the medical record. Specifically, code 96372 is assigned a 
Q1 indicator (Packaged APC payment if billed on the same claim as a HCPCS code assigned status indicator 
S, T, or V"). CPT code 99284 25 was assigned final status indicator V since the APC assigned was 
5024. These services would not be separately payable. Based on this information, we decided that Medicare 
rules for coverage of procedure code 96372 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 96372 for date of service May 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient services provided on June 
12, 2023. 
 
You asked the Plan to waive the coinsurance for the outpatient services. You say that you are unhappy with 
cost share. 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 10% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 10% coinsurance for the outpatient services. 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. The total amount you owe is $29.51, which is 10% 
coinsurance of the allowed amount for each item. Therefore, we decided that the Plan does not have to waive 
the coinsurance for the outpatient services provided on June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical examination for a driver's license provided on 
May 2, 2023. 
 
You asked the Plan to pay for the medical examination. You say that the examination was medically necessary.  
The Plan denied your request. The Plan says an examination for a driving license to maintain employment is a 
clear exclusion as shown in the Evidence of Coverage.  
 
The Plan must follow Medicare rules. Medicare rules say that the routine physical checkup exclusion applies to 
examinations required by third parties such as insurance companies, business establishments, or Government 
agencies. 
 
We looked at the file, the Plans rules and Medicare rules. The Plan and Medicare do not cover routine physical 
checkups required by third parties such as insurance companies, business establishments, or Government agencies. Therefore, we decided that the Plan does not have to pay for a medical examination for a driver's 
license provided on May 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dialysis provided on July 1, 2023, by an out-of-network 
(OON) provider.  
 You asked the Plan to pay for dialysis. You say that you cannot stop treatment and must continue treating the 
patient until they change providers or insurance. The Plan denied your request. The Plan says that their original 
decision to deny payment was correct. 
 
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 dialysis provided on July 1, 2023, by an OON 
provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound provided on May 11, 2023. 
 
You asked the Plan to pay for the ultrasound. You say that you are requesting reconsideration for the service 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the ultrasound provided 
on May 11, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0482 provided on July 27, 2023. 
 
You asked the Plan to pay for procedure code G0482. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that code G0482 is bundled into payment for 
code 80307. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS has withdrawn the rule stating that code 
G0482 is bundled into code 80307. Code G0482 is now separately payable from code 80307 in accordance 
with the bulletin that CMS published on its website along with the 2023 Q4 NCCI files.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code G0482 have been met. Therefore, we decided that the Plan has to pay for procedure code 
G0482 provided on July 27, 2023.  
 
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 code 0012M for date of service June 2, 2023. 
 
You asked the Plan to pay for code 0012M. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services rendered are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that code 0012M for CxBladder is non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 0012M have not been met. Therefore, we decided that the Plan does not have to pay for code 
0012M for date of service June 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the health club membership (S9970) 
purchased on January 1, 2022. 
 
You asked the Plan to issue reimbursement 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 this service is not payable as you 
have submitted your reimbursement request untimely.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.   
 
 
The Plans rules for coverage of gym benefits have not been met because your request for reimbursement was 
received untimely. Specifically, the Plans contract states that reimbursement requests for the wellness 
allowance benefit must be received by March 31
st
 of the following year. However, your request in this case was 
received by the Plan untimely on July 27, 2023. Therefore, we decided that the Plan does not have to issue 
reimbursement for the health club membership (S9970) purchased on January 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on May 30, 2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that you dont need two doctors. 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 $35 
copayment for physician/practitioner services, Including doctors office visits. 
 
You have been asked to pay a $35 copayment for the 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 waive the copayment for the office visit provided on May 30, 2023.