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

 
We decided that the Plan does not have to pay for laboratory services provided on March 21, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this service is supported in the records. 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 laboratory services 
provided on March 21, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the physical therapy visits (97110, 97112, 
97162, 97164) provided on November 16, 2022, to December 20, 2022. 
 
You asked the Plan to reduce the copayment for the physical therapy visits (97110, 97112, 97162, 97164). You 
say that your copayment should be $25 per visit, not $40. 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 $40 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for the physical therapy visits (97110, 97112, 97162, 97164). 
This item/service falls within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. The total you owe is $240 ($40 copayment x 6 
visits = $240). Therefore, we decided that the Plan does not have to reduce the copayment for the physical 
therapy visits (97110, 97112, 97162, 97164) provided on November 16, 2022, to December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health visit provided on August 02, 2023. 
 
You asked the Plan to pay for the mental health 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 the mental health visit 
provided on August 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 17, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are a primary care office, and this was for 
primary care. 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 May 17, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on July 06, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. 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 home visit provided on 
July 06, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 95861 rendered on May 18, 
2022. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation does not support two units of CPT 95861. 
 
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 95861 is "Needle electromyography; 2 extremities with 
or without related paraspinal areas." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provided records in this case document intraoperative neurophysiologic monitoring during a surgery for spinal stenosis. A baseline needle 
electromyograph was reported on May 18, 2022, at 08:18:51 and an electromyograph was reported to have 
been performed throughout the procedure which reportedly began with the initial incision on May 18, 2022, at 
08:24:35. Provided records do not support that the two electromyographs were separate and distinct procedures 
to meet criteria for coverage for two units of CPT 95861. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for two units of procedure code 95861 rendered on May 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye exam provided on January 11, 2023. 
 
You asked the Plan to pay for a medical eye exam. You say that you were told that the provider was in-
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 medical eye exam 
provided on January 11, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing (G0483) provided on July 20, 2023. 
 
You asked the Plan to pay for drug testing. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says that payment for code G0483 is bundled into payment for code 80305. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS is withdrawing NCCI PTP edits between 
Column One codes 80305, 80306, and 80307 for presumptive test(s), and Column Two codes G0480  G0483, 
and G0659 for definitive test(s). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of drug testing have been met. Specifically, the edit between codes G0483 and 80305 has been 
withdrawn, and the withdrawal is retroactive. Therefore, we decided that the Plan has to pay for drug testing 
(G0483) provided on July 20, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the MRI provided on June 23, 2023. 
 
You asked the Plan to pay more for the MRI. You say that you would like additional payments 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. The 
enrollees contract with the Plan says that there is a $400 deductible which applies to outpatient diagnostic tests 
and therapeutic services and supplies.  
 
The enrollee has been asked to pay $357.83 towards their $400 deductible for the MRI. The item or service you 
asked the Plan to pay more 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 $400 
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 the MRI was received on June 23, 2023. Therefore, 
we decided that the Plan does not have to pay more for the magnetic resonance imaging (MRI) provided on 
June 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injection services provided on July 27, 
2023. 
 
You asked the Plan to waive the copayment for the injection services. You say that you have not had a 
copayment for this service in the past. 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 $245 
copayment for in-network outpatient surgery, including services provided at ambulatory surgical centers. 
 
You have been asked to pay a $245 copayment for the injection services. This item/service falls within the in-network outpatient surgery, including services provided at 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 the injection services provided on July 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery provided on June 28, 
2023. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you want to appeal the 
amount being charged. 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 surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $325 copayment for the outpatient surgery. 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 the outpatient surgery provided 
on June 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 07, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you were unaware the provider was OON. 
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 laboratory services 
provided on March 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on August 10, 2023. 
 
You asked the Plan to pay for the nursing facility care. 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 nursing facility care 
provided on August 10, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) stay 
provided on June 06, 2023, to June 07, 2023. 
 
You asked the Plan to waive the copayment for the skilled nursing facility (SNF) stay. You say that the time for 
inpatient skilled nursing was approved. Therefore, you should not receive a bill for services. 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 $188 
copayment for skilled nursing facility (SNF) care.  
You have been asked to pay a $188 copayment for the skilled nursing facility (SNF) stay. This item/service 
falls within the skilled nursing facility (SNF) care 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 $376 ($188 copayment x 2 days = $376). 
Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) 
stay provided on June 06, 2023, to June 07, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 13, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient surgery provided on April 
24, 2023. 
 
You asked the Plan to waive the coinsurance for the outpatient surgery. You say that you disagree with the 
coinsurance responsibility and would like the plan to reconsider. 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 25% 
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay 25% coinsurance for the outpatient surgery. 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. The 
total you owe is $30.84 ($123.37 allowed amount x 25% = $30.84). Therefore, we decided that the Plan does 
not have to waive the coinsurance for the outpatient surgery provided on April 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each automatic external defibrillator 
monthly rental provided on February 20, 2023, to March 20, 2023. 
 
You asked the Plan to waive the coinsurance for each automatic external defibrillator monthly rental. You say 
that you were told that the item would be fully covered. 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 and related supplies. 
 
You have been asked to pay 20% coinsurance for each automatic external defibrillator monthly rental. This 
item/service falls within the durable medical equipment and related 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 amount you owe for each rental is 
$736.78. The total amount you owe is $1,473.56 ($736.78 coinsurance x 2 months = $1,473.56). Therefore, we 
decided that the Plan does not have to waive the coinsurance for each automatic external defibrillator monthly 
rental provided on February 20, 2023, to March 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on July 3, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel should be billed 
with one unit of one 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 lab panel provided on July 3, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
July 19, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you cannot afford 
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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance transportation. 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 the 
ambulance transportation provided on July 19, 2023.