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

 
We decided that the Plan does not have to increase the reimbursement for the chiropractic services provided 
from February 4, 2022, to October 24, 2022. 
 
You asked the Plan to increase the reimbursement for the chiropractic services. You say that you feel as though 
you should be reimbursed more. The Plan denied your request. The Plan says this cost sharing was reimbursed 
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 30% 
coinsurance for out-of-network chiropractic services.  
 
 
 You have been asked to pay 30% coinsurance for the chiropractic services. This item/service falls within the 
chiropractic services benefit category.  
 
Date of Service Items Allowed Amount 30% Coinsurance 
February 4, 2022 Chiropractic services $114.84 $34.45 
February 15, 2022 Chiropractic services $30.96 $9.29 
October 24, 2022 Chiropractic services $27.42 $8.23 
 
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 increase the reimbursement for the chiropractic services provided from February 4, 
2022, to October 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 24, 2023. 
 
You asked the Plan to pay for the lab services. You say that this testing is covered by Medicare and 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 provided on March 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87491, 87563, 86400, 87653, 87798, 
87641, 87500) provided on May 22, 2023. 
 
You asked the Plan to pay for the lab services. You say that these 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 87481, 87491, 87563, 86400, 87653, 87798, 87641, & 87500 are not supported in the 
medical record. Specifically, multiple unbundled codes were billed for a single lab 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 (87481, 87491, 87563, 86400, 87653, 87798, 87641, 
87500) provided on May 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the pelvis before 
and after contrast (72197).  
 
You asked the Plan to pre-approve the MRI. You say that you have leg weakness and arm weakness. You say 
you cannot tolerate needles to get electromyography (EMG). The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 the MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found you are noted to have lower extremity 
weakness which may be multifactorial in nature. However, the records provided did not readily indicate a 
pathophysiology for your complaints that would localize to the imaging being performed in this case. 
Alternative imaging studies would otherwise be more appropriate at this context. Therefore, it cannot be 
independently determined that the requested service would be reasonable and necessary. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the pelvis before and after contrast (72197).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0013M provided on April 3, 2023. 
 
You asked the Plan to pay for procedure code 0013M. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are 
non-covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the 
Plan does not have to pay for procedure code 0013M provided on April 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a crown (D2740) provided on June 13, 
2023. 
 
You asked the Plan to waive the coinsurance for a crown. You say that the Plan should pay more. 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 50% 
coinsurance for dental services.  
 
You have been asked to pay a 50% coinsurance of the allowance amount for a crown. This item/service falls 
within the dental 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 coinsurance for a crown 
(D2740) provided on June 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate (0421T). 
 
You asked the Plan to pre-approve the waterjet ablation. You say that you have had this issue for the last 9 
years. You say that in 2022 you had the Urolift procedure done with no positive results. You also say that you 
feel that your age should not be a problem for this procedure as you are in good health and are currently very 
active. The Plan denied your request. The Plan says this request is not medically necessary because the records 
show that you are over the age of 80. 
 The Plan must follow Medicare rules. Medicare rules say that treatment for lower urinary tract symptoms 
(LUTS)/benign prostatic hyperplasia (BPH) treatment will be considered reasonable and necessary when 
performed once in patients aged 80 or under. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the waterjet ablation have not been met. Therefore, we decided that the Plan does not have to pre-
approve transurethral waterjet ablation of the prostate (0421T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection(s) provided on February 15, 2023. 
 
You asked the Plan to pay for injection(s). 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 injection(s) provided on 
February 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator and portable gaseous 
oxygen system. 
 
You asked the Plan to pre-approve a portable oxygen concentrator and portable gaseous oxygen system. You 
say that you want to use a company that is close to you. You say that your current concentrator has went out on 
you and the tanks with the current DME provider only goes up to a level 3 flow and you need a level 4 flow. 
The Plan denied your request. The Plan says that the rental benefits have been exhausted.  
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 a portable oxygen concentrator and 
portable gaseous oxygen system Our reviewer says that a portable oxygen concentrator and portable gaseous 
oxygen system is not medically necessary. Our physician reviewer found that the records do no documents that 
your present oxygen equipment has been lost, stolen, irreparably damaged in a specific accident or natural 
disaster or has reached its reasonable useful lifespan to meet Medicare criteria for replacement. Also, the 
medical records do not document a medical need to change the equipment vendor. Therefore, switching 
suppliers and being provided new oxygen equipment is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable oxygen concentrator and portable gaseous oxygen system have not 
been met.  Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator 
and portable gaseous oxygen system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the nephrology services to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the nephrology services. You say that you are requesting reconsideration of 
the denied service. The Plan denied your request. The Plan says the service was not approved. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the nephrology services to be provided by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 09, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with 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 a $65 
copayment for ambulance services. 
 
You have been asked to pay a $65 copayment for ambulance services. This item/service falls within the 
ambulance 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 ambulance services 
provided on June 09, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OmniGraf testing (81479) provided on November 10, 
2022. 
 
You asked the Plan to pay for the OmniGraf testing. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory providers who bill molecular 
diagnostic tests must register test services on the DEX Diagnostics Exchange. 
 
We looked at the file and Medicare rules. The genetic testing in this case is not covered per the DEX 
Diagnostics Exchange. Based on this information, we decided that Medicare rules for coverage of the 
OmniGraf testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
OmniGraf testing (81479) provided on November 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal testing billed with code 81479 for date 
of service May 10, 2023. 
 
You asked the Plan to pay for the Guardant Reveal testing. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant Reveal testing is not covered. 
 
We find that the Guardant Reveal is the service at issue. This testing is specifically not covered. Based on this 
information, we decided that Medicare rules for coverage of the Guardant Reveal testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant Reveal testing billed with code 
81479 for date of service May 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on May 17, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the Plan should pay more. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing 
amount when your services are received from an out-of-network provider.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for dental services provided on May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 15, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on June 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on January 06, 2023, to May 04, 2023. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you disagree 
with the coinsurance. 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 durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for durable medical equipment (DME). This item/service falls 
within the durable medical equipment (DME) 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 durable medical equipment (DME) provided on January 06, 2023, to May 04, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a office visit provided on July 31, 2023. 
 
You asked the Plan to waive the copayment for a office visit. You say that you disagree with 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 a $10 
copayment for physician/practitioner services/PCP officevisits. 
 
You have been asked to pay a $10 copayment for a office visit. This item/service falls within the 
physician/practitioner services/PCP officevisits benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for a office visit provided on July 31, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health visits provided on May 16, 2023, to July 
10, 2023. 
 
You asked the Plan to pay for the mental health visits. 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 mental health visits 
provided on May 16, 2023, to July 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy provided on May 31, 2023. 
 
You asked the Plan to waive the copayment for an endoscopy. You say that you believe the copay should be 
$50 for this service. 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 $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $350 copayment for an endoscopy. This item/service falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 an endoscopy provided on May 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with a patient 
weight capacity up to and including 300 pounds (K0861) and additional items and accessories (codes E0955, 
E1007, E1012, E1028, E2209, E2300, E2311, E2313, E2361, E2377, E2607, and E2613). 
 
You asked the Plan to pre-approve the group 3 standard power wheelchair and additional items and accessories. 
The Plan denied your request. The Plan says the enrollee's weight is not appropriate for which the requested 
group 3 power wheelchair is covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a PWC is covered if the beneficiarys weight is 
less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 
95% of the weight capacity of the next lower weight class PWC. Medicare rules also say if the base PWC is not 
covered, then related accessories will be denied. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the group 3 standard power wheelchair and additional items and accessories have not been met. 
Specifically, the provided records show that your most recent documented weight is above the required weight 
limit of up to and including 300 pounds for the requested group 3 standard power wheelchair (K0861). 
Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with a 
patient weight capacity up to and including 300 pounds (K0861) and additional items and accessories (codes 
E0955, E1007, E1012, E1028, E2209, E2300, E2311, E2313, E2361, E2377, E2607, and E2613).