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

 
We decided that the Plan does not have to waive the deductible for a breast ultrasound provided on December 
29, 2022. 
 
You asked the Plan to waive the deductible for an ultrasound. You say that you should only owe a copayment 
for this test. You have had it before and that was always how it worked. 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. Your 
contract with the Plan says that there is a $200 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. You have been asked to pay $193.94 towards this deductible. 
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $200 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  This cost sharing is a contractual obligation that had not been met at the time an ultrasound was received on 
December 29, 2022. Therefore, we decided that the Plan does not have to waive the deductible for a breast 
ultrasound provided on December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 18, 2023, billed with 
procedure code 72170-26. 
 
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 claim was billed with an inappropriate 
diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that it is not appropriate to bill a left and right sided 
diagnosis code when a bilateral code is available.  
We looked at the file and Medicare rules. We find that the claim was inappropriately billed with a right side 
and left side diagnosis as there is a bilateral diagnosis code available. Based on this information, we decided 
that Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for practitioner services provided on March 18, 2023, billed with procedure 
code 72170-26.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each outpatient surgery provided on August 
16, 2023, to August 30, 2023. 
 
You asked the Plan to waive the copayment for each outpatient surgery. You say that you are asking for a more 
reasonable charge for an elderly patient. 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 $150 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
You have been asked to pay a $150 copayment for each outpatient surgery. This item/service falls within the 
outpatient surgery and other medical 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. 
The total you owe is $450 ($150 copayment x 3 visits = $450). Therefore, we decided that the Plan does not 
have to waive the copayment for each outpatient surgery provided on August 16, 2023, to August 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 15, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and 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 procedure code.  
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a magnetic resonance imaging service 
provided on July 14, 2023. 
 
You asked the Plan to reduce the copayment for a magnetic resonance imaging service. You say that you 
should only be charged a $210 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 $250 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $250 copayment for a magnetic resonance imaging service. This item/service falls within the in-network 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 reduce the copayment for a magnetic resonance imaging service provided on July 14, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle libre 14 continuous glucose monitor system.  
You asked the Plan to pre-approve Freestyle libre 14 continuous glucose monitor system. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of Freestyle libre 14 continuous glucose monitor system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Freestyle libre 14 continuous glucose monitor system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 10, 2023, billed with 
procedure code 99239. 
 
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 claim was billed with an invalid place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the place of service code is generally used to 
reflect the actual setting where the beneficiary receives the face-to-face service.  
 
We looked at the file and Medicare rules. This claim was inappropriately billed with POS 22, as the enrollee 
was registered inpatient on this date of service. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on April 10, 2023, billed with procedure code 99239.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision components provided on February 10, 2022. 
  
You asked the Plan to pay for the vision components. You say that this was the only eyeglasses claim you filed 
in 2022. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when pays up to $125 combined allowance for eyeglasses and contact 
lenses every 24 months. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $125 on August 24, 2021, which 
exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the vision 
components have not been met. Therefore, we decided that the Plan does not have to pay for the vision 
components provided on February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 27, 2022. 
 
You asked the Plan to pay for the office visit. You say that you are asking for the review for the submitted 
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 office visit provided 
on December 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on July 30, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
stung by a dozen bees and your wife had to call 911. You also say that your vitals were checked, a decision to 
not go to the hospital was made and you feel that the health plan should have covered at least some of the cost. 
The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 30, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on July 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the test panel provided on April 28, 2023, and billed with 
codes 87496, 87486, 87653, 87651, 87532, 87581, 87798, and 87491. 
 
You asked the Plan to pay for the test panel. You say that this testing was medically necessary. The Plan denied 
your request. The Plan says per Local Coverage Article (LCA) A58761, this type of testing must be billed as a 
single unit of service with a single code. 
 
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 the test panel provided on April 28, 2023, and billed with codes 87496, 87486, 
87653, 87651, 87532, 87581, 87798, and 87491.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power mobility device provided on March 28, 2023. 
 
You asked the Plan to pay for the wheelchair. You say that this should be paid for. The Plan denied your 
request. The Plan says this provider does not participate in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program. 
 
The wheelchair supplies for this case is not eligible to bill Medicare. The plan did not pre-approve the 
wheelchair. We found no exception that would require the plan to pay for these services. Based on this 
information, we decided that Medicare rules for coverage of the wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pay for a power mobility device provided on March 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on September 13, 2023. 
 
You asked the Plan to pay for the lab testing. 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 lab testing provided 
on September 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on July 14, 2023. 
 
You asked the Plan to pay for the lab testing. You say that requesting reconsideration stating we are requesting 
retro-authorization for the services billed and have enclosed documentation that supports medical necessity of 
the procedures on the 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 lab testing provided 
on July 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each outpatient service provided on May 
24, 2023, to May 31, 2023. 
 
You asked the Plan to waive the copayment for each outpatient service. You say that you believe that you 
should only be liable for the first 5 days of you inpatient stay. 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 $295 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
You have been asked to pay a $295 copayment for each outpatient service. This item/service falls within the 
outpatient surgery and other medical 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. 
However, since the allowed amount is less than the standard copayment for each service, you owe $1,593.84. 
Therefore, we decided that the Plan does not have to waive the copayment for each outpatient service provided 
on May 24, 2023, to May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on May 4, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided on May 4, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an ultrasound provided on August 3, 2023. 
 
You asked the Plan to waive the deductible for an ultrasound. You say that this service should be a part of the 
preventative screening. 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. Your 
contract with the Plan says that there is a $230 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
 
 
 
 You have been asked to pay $102.36 towards your $230 deductible for the ultrasound. The item or service you 
asked the Plan to waive the deductible for falls within the outpatient diagnostic tests and therapeutic services 
and supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $230 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. 
This cost sharing is a contractual obligation that had not been met at the time an ultrasound was received on 
August 3, 2023. Therefore, we decided that the Plan does not have to waive the deductible for an ultrasound 
provided on August 3, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray provided on March 12, 2023. 
 
You asked the Plan to pay for the x-ray. You say that this should be paid for. 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 J96.090 has an Excludes1 note in relation to R09.02. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a 
chest x-ray provided on March 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the catheter supplies provided on April 18, 2023. 
 You asked the Plan to pay for the catheter supplies. 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 catheter supplies 
provided on April 18, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (96130, 96137, 96136, 
90791) provided on July 10, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient mental health services. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the service was not pre-authorized 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 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 outpatient mental health services (96130, 96137, 96136, 90791) provided 
on July 10, 2023, by an out-of-network (OON) provider.