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

 
We decided that the Plan does not have to pay for the Tempus xR tumor testing (81456) provided August 6, 
2023. 
 
You asked the Plan to pay for the laboratory testing. You say that the Tempus requisition form completed by 
the ordering provider contains the information indicating that this test is medically necessary. The Plan denied 
your request. The Plan says based on Medicare guidelines, the genetic test, Tempus xR solid tumor testing 
requested does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The genetic test ordered does not have approval by the Food and Drug 
Administration (FDA) or a certification by third party called CLEP. Medicare rules say that items and services 
that are not medically necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the Tempus xR tumor testing (81456) provided August 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for eye injections provided from August 15, 2023, to 
October 10, 2023. 
 
You asked the Plan to waive the cost for eye injections. You say that you get these injections every month and 
cannot afford these costs. 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 $20 
copayment for outpatient diagnostic tests and therapeutic services and supplies, and a 20% coinsurance for 
Medicare Part B prescription drugs.  
 
 You have been asked to pay a $1,107.84 total cost for eye injections ($20 + $350.27 = $370.27) ($370.27 x 3 
months = $1,110.81. Youve been asked to pay $1,107.84 which is less than the full amount). This item/service 
falls within the outpatient diagnostic tests and therapeutic services and supplies and Medicare Part B 
prescription 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 cost for eye injections provided 
from August 15, 2023, to October 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 30, 2023, billed with 
procedure code 99232. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the service is not supported without the requested 
documentation. 
 
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 the practitioner services provided have 
been met. Specifically, no medical records have been provided for the date of service in question. Therefore, 
we decided that the Plan does not have to pay for practitioner services provided on April 30, 2023, billed with 
procedure code 99232.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 5, 2023, billed with 
procedure code 00732-QX. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that K75.0 has an Excludes1 note in relation to K83.09. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the practitioner services provided have not been met. Therefore, we decided that the Plan does 
not have to pay for practitioner services provided on May 5, 2023, billed with procedure code 00732-QX.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 26, 2023, billed with 
codes 87481, 87500, 87640, 87652, 87798, 87798, 87799 and 87900. 
 
You asked the Plan to pay for laboratory services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says panel testing should be billed using one Current Procedural 
Terminology (CPT) code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided on January 26, 2023, billed with codes 87481, 
87500, 87640, 87652, 87798, 87798, 87799 and 87900.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on July 5, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the documentation requirements have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity. 
 
We looked at the file and Medicare rules. The record does not contain a valid proof of delivery. Specifically, there 
was no signed receipt of the delivery. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the supply 
allowance for a continuous glucose monitor (CGM) provided by an out-of-network provider on July 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 81479 for date of 
service July 18, 2023.  
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. 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 laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed 
with code 81479 for date of service July 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a panoramic 
radiographic image (D0330) provided on September 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services were required from your new 
provider. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
   
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on dates of service February 22, 2023, and 
August 22, 2023. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation 
(D0150) and a panoramic radiographic image (D0330) provided on September 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adult prophylaxis (D1110) provided on September 7, 
2023.  
 
You asked the Plan to pay for the dental services. You say that you have documented periodontal disease. You 
also say you would like the Plan to pay for up to four cleanings a year. The Plan denied your request. The Plan 
says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 24, 2023. Therefore, 
we decided that the Plan does not have to pay for an adult prophylaxis (D1110) provided on September 7, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99205) provided on September 6, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that please see attached medical records that supports 
services billed. Please review for reconsideration of payment. 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. 
 
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 outpatient office visit (99205) provided on 
September 6, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays-four radiographic images (D0274) 
provided on August 8, 2023. 
 
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 your benefit for the service provided has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the service provided was exhausted on date of service February 7, 2023.  
  
 
Specifically, the Plans contract states that one set of bitewing x-rays are covered every twelve months. You 
previously received this service on February 7, 2023, less than twelve months prior, which was paid for by the 
Plan. Therefore, you have exhausted the allowable benefit for the service provided in this case. Therefore, we 
decided that the Plan does not have to pay for the bitewing x-rays-four radiographic images (D0274) provided 
on August 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement of nails by any method (11721) provided on 
September 13, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the debridement services. You say that this care was critical to this enrollee's 
overall health and well-being.  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. 
 
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 debridement of nails by any method (11721) 
provided on September 13, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services and crown (D2950, D2740) provided 
on June 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core 
buildup services and crown (D2950, D2740) provided on June 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit provided on September 26, 
2023. 
 
You asked the Plan to pay for an office or other outpatient visit. You say that the services were medically 
necessary 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 an office or other 
outpatient visit provided on September 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foreign medical services provided from March 18, 2023, 
to April 14, 2023. 
 
You asked the Plan to pay for the foreign medical services. You say that you were not well with sciatica pain 
while you were out of the country. You say that you provided the bills, totaling $1,200. You also say that you 
feel you should be refunded for these services. The Plan denied your request. The Plan says it cannot be 
determined if the services you received were urgent or emergent in nature. 
 
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 the foreign medical services have been 
met. Specifically, the provided documentation does not include medical records. Without medical records it 
cannot be determined that the services you received were urgent or emergent in nature. Therefore, we decided 
that the Plan does not have to pay for the foreign medical services provided from March 18, 2023, to April 14, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a right shoulder procedure provided on 
September 22, 2023. 
 
You asked the Plan to waive the copayment for a right shoulder procedure. You say that you do not understand 
why the copayment for this is so high. 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 $325 
copayment for outpatient hospital services. 
 
You have been asked to pay a $325 copayment for a right shoulder procedure. This item/service 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. However, since the allowed amount is less than the standard copayment, you only owe 
$309.36. Therefore, we decided that the Plan does not have to waive the copayment for a right shoulder 
procedure provided on September 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
June 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that the items should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the items denied correctly as the rendering 
provider is not enrolled with 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 pay for a continuous glucose monitor (CGM) 
(A4239) provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99214) provided on August 10, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit . You say that you have attached documentation that supports the 
medical necessity of this service. Please review for payment. 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. 
 
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 outpatient office visit (99214) provided on 
August 10, 2023, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram and critical care services provided on 
January 31, 2023. 
 
You asked the Plan to pay for the electrocardiogram and critical care services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says it is the providers responsibility to bill the 
primary group health plan or any liability insurance before submitting the claim to the members Plan. The plan 
did not receive a primary carriers Explanation of Benefits. 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
the primary carriers Explanation of Benefits. As the secondary insurer, the Plan cannot be held responsible for 
the electrocardiogram and critical care services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for an electrocardiogram and critical care services 
provided on January 31, 2023.