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

 
We decided that the Plan does not have to pay for the laboratory service provided on November 07, 2022. 
 
You asked the Plan to pay for the laboratory service. 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 laboratory service 
provided on November 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an outpatient hospital visit provided on 
January 16, 2023. 
 
You asked the Plan to waive the deductible for an outpatient hospital visit. You say that the facility did not 
inform you of the cost share and ask for permission to continue with performing the 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. Your 
contract with the Plan says that there is a $400 deductible which applies to outpatient hospital services.  
 
The item or service you asked the Plan to waive the copayment for falls within the outpatient hospital services 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 
deductible which applies to outpatient hospital services. This cost sharing is a contractual obligation that had 
not been met at the time an outpatient hospital visit was received on January 16, 2023. Therefore, we decided 
that the Plan does not have to waive the deductible for an outpatient hospital visit provided on January 16, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the federally qualified health center visit, the office visit, and 
the osteopathic manipulative treatment provided on April 14, 2023. 
 
You asked the Plan to pay for the federally qualified health center visit, the office visit, and the osteopathic 
manipulative treatment. 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 federally qualified 
health center visit, the office visit, and the osteopathic manipulative treatment provided on April 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 13, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on June 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on June 27, 2023. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says the PCR testing is considered unproven and not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 pay for the urine PCR panel testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the standard of care for the evaluation of urinary incontinence is urinalysis with 
urine culture and sensitivity. The PCR testing is considered unproven and 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 the urine PCR panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on June 27, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture and manual therapy provided on June 21, 2023. 
 
You asked the Plan to pay for acupuncture and manual therapy. You say that you are appealing the claim 
payment denial. 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 acupuncture and manual 
therapy provided on June 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 61783, 22612, 69990, 63044, and 63042 for date of 
service February 28, 2023. 
 
You asked the Plan to pay for codes 61783, 22612, 69990, 63044, and 63042. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant 
service is a physician, PA, NP, or CNS for code 61783. Medicare only makes payment for surgical assistant 
services when provided by one of these types of practitioners. 
 
Medicare rules say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. In this case, we have confirmed that codes 22612 and 69990 are column two codes to 
column one code 22633 with a modifier indicator of 0. The column two code is therefore not payable. 
In this case, we have confirmed that codes 63042 and 63044 are column II codes to column I code 22633. This 
claim has not been billed with an appropriate modifier to bypass the edit. 
 
Therefore, we decided that the Plan does not have to pay for codes 61783, 22612, 69990, 63044, and 63042 for 
date of service February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fundus photograph and the eye exam provided on March 
27, 2023, to July 24, 2023, by an OON provider.  
 
You asked the Plan to pay for a fundus photograph and the eye exam. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says the service was not 
authorized. 
 
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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 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 a fundus photograph and the eye exam provided 
on March 27, 2023, to July 24, 2023, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20680 rendered on April 30, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 20680 LT (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 20680 is "Removal of implant; deep (eg, buried wire, pin, 
screw, metal band, nail, rod or plate)." 
 
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 in this case, if a superficial or 
deep implant (e.g., buried wire, pin, rod) requires surgical removal (CPT codes 20670 and 20680), it is not separately reportable if it is performed as an integral part of another procedure 
 
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 procedure code 20680 rendered on April 30, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a psychiatric diagnostic evaluation 
provided on January 09, 2023. 
 
You asked the Plan to reduce the coinsurance for a psychiatric diagnostic evaluation. You say that you were 
told that the provider was in-network. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 40% 
coinsurance for out-of-network mental health services provided in a specialists office. 
 
You have been asked to pay 40% coinsurance for a psychiatric diagnostic evaluation. This item/service falls 
within the out-of-network mental health services provided in a specialists office 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 $59.35 ($148.38 
allowed amount x 40% = $59.35). Therefore, we decided that the Plan does not have to reduce the coinsurance 
for a psychiatric diagnostic evaluation provided on January 09, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies billed with code A4223 for date of service May 
26, 2023, to June 1, 2023. 
 
You asked the Plan to pay for the supplies billed with code A4223. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the items rendered are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that supplies used with disposable drug delivery 
systems are non-covered items. 
 
We looked at the file and Medicare rules. Review of the file shows that the items at issue are for the use in a 
disposable drug delivery system. This is specifically not covered. Based on this information, we decided that 
Medicare rules for coverage of the supplies billed with code A4223 have not been met. Therefore, we decided 
that the Plan does not have to pay for the supplies billed with code A4223 for date of service May 26, 2023, to 
June 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 27, 2022, billed with 
codes 87481, 87500, 87640, 87652, 87653, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 27, 2022, billed with codes 87481, 87500, 87640, 87652, 87653, and 87798.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each sensory integrative technique 
provided on October 12, 2022, to December 28, 2022. 
 
You asked the Plan to waive the copayment for each sensory integrative technique. You say that you say that 
you thought it was misleading for the provider to tell you $100, which you paid for already, and then bill you 
an additional $35 per visit. 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. 
 
You have been asked to pay a $20 copayment for each sensory integrative technique. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $220 ($20 
copayment x 11 visits = $220). Therefore, we decided that the Plan does not have to waive the copayment for 
each sensory integrative technique provided on October 12, 2022, to December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on June 05, 2023. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you do not feel responsible for the 
cost share applied. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for an injection. This item/service falls within the 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. The total coinsurance you owe is $525.93, which is 20% of the allowed amount for Medicare Part B drug injections ($2,629.66 allowed x 20% = $525.93). Therefore, we decided that the Plan does not have to 
waive the coinsurance for an injection provided on June 05, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric evaluation and the psychotherapy provided on 
November 22, 2022, to June 22, 2023. 
 
You asked the Plan to pay for the psychiatric evaluation and the psychotherapy. 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 psychiatric 
evaluation and the psychotherapy provided on November 22, 2022, to June 22, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance ground mileage provided on April 7, 2023. 
 
You asked the Plan to pay for the ambulance ground mileage provided on April 7, 2023. You say to please 
review the submitted copy of the claim form as it is clearly indicating 4.0 miles for service code A0425. The 
Plan denied your request. The Plan says that the plan requires mileage under 100 miles to be reported to the 
tenth of a mile. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a specific citation or clear documentation 
to support their argument for denial. The claim shows that 4.0 units of mileage are reported, which is 
reported to the nearest tenth of a mile. The Plan has not substantiated their denial in this case Therefore, we 
decided that the Plan has to pay for ambulance ground mileage provided on April 7, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 08, 2023. 
 
You asked the Plan to pay for an office visit. You say that the referral is 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 an office visit provided 
on June 08, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network diagnostic mammogram 
provided on May 31, 2023. 
 
You asked the Plan to waive the copayment for an in-network diagnostic mammogram. You say that you 
understand the $60 copayment, but not the $45 one? Why were you charged for this mammogram? 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 $60 
copayment for outpatient diagnostic tests and therapeutic services andsupplies. 
 
You have been asked to pay a $60 copayment for an in-network diagnostic mammogram. This item/service 
falls within the outpatient diagnostic tests and therapeutic services andsupplies 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 $45. Therefore, we decided that the Plan does not have to 
waive the copayment for an in-network diagnostic mammogram provided on May 31, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable x-rays of the lower leg provided on April 24, 2023. 
 
You asked the Plan to pay for portable x-rays of the lower leg. You say that these 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 portable x-rays of the 
lower leg provided on April 24, 2023.