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

 
We decided that the Plan does not have to pay for the internal medicine services provided on October 05, 2023. 
 
You asked the Plan to pay for the internal medicine services. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 internal medicine services provided on October 05, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Allosure Kidney genetic testing (81479) provided on 
December 3, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you have reported the service at issue correctly. The 
Plan denied your request. The Plan says this molecular pathology testing is not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. The Plan has documented that the genetic testing at issue has not 
been approved by the MolDX contractor as having met Medicare reasonable and necessary requirements. 
Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for Allosure Kidney genetic testing (81479) provided 
on December 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression devices (E0675, E0673) 
provided on August 11, 2023. 
 
You asked the Plan to pay for the pneumatic compression devices. You say that these devices were provided 
for use during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility 
for a procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The items at issue in this appeal were for use outside of the home. Although these items may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. 
  Therefore, we decided that the Plan does not have to pay for the pneumatic compression devices (E0675, 
E0673) provided on August 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87481, 87640, 87652, 87798 and 
87799) billed for date of service August 30, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was necessary and is supported as 
billed. The Plan denied your request. The Plan says these services comprise a test panel which should be billed 
with a single panel 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 laboratory panel (87481, 87640, 87652, 87798 and 87799) billed for date of 
service August 30, 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 October 5, 2023, and billed with codes 87481, 87500, 87640, 87652, 87798, 87799, and 87900. 
 
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 unbundling of lab codes for PCR panel testing is not 
appropriate. 
 
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 urine polymerase chain reaction (PCR) panel testing provided on October 5, 
2023, and billed with codes 87481, 87500, 87640, 87652, 87798, 87799, and 87900.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections provided on February 28, 2023, 
to July 06, 2023. 
 
You asked the Plan to waive the copayment for injections. You say that if you had known that your injections 
would go to your naturopath benefit, you would have paid out of pocket. 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 Naturopathy. 
 
You have been asked to pay a $20 copayment for injections. This item/service falls within the Naturopathy 
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. you 
have been asked to pay $232.77 for a series of injections. Therefore, we decided that the Plan does not have to 
waive the copayment for injections provided on February 28, 2023, to July 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-evaluation (D0171) provided on January 12, 2023. 
 
You asked the Plan to pay for the dental service. You say that the jawbone was removed due to your stage 4 
cancer diagnosis. You also say that this is why this visit should be covered. The Plan denied your request. The 
Plan says this service is not listed as a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the service in this case is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-evaluation 
(D0171) provided on January 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on September 27, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you were told the x-rays were covered as part of 
your bi-annual teeth cleaning. You also say that you feel you should not be held liable for the outstanding 
charges. The Plan denied your request. The Plan says your benefit for the service in this case has already been 
exhausted.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for service in this case was exhausted on date of service March 15, 2023. Therefore, we 
decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on September 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on August 22, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
You also say to please review the appeal letter and process the claim. The Plan denied your request. The Plan 
says the provider is not a plan contract provider and is not enrolled in Medicare as a durable medical equipment 
supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on August 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88305, 88313 and 88342 billed for date of 
service May 23, 2023. 
 
You asked the Plan to pay for procedure codes 88305, 88313 and 88342. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 88305, 88313 and 88342 are not supported. Specifically, a physician order for the 
services at issue has not been provided for review. Based on this information, we decided that Medicare rules 
for coverage of procedure codes 88305, 88313 and 88342 have not been met.  
  Therefore, we decided that the Plan does not have to pay for procedure codes 88305, 88313 and 88342 billed 
for date of service May 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a seat lift mechanism, electric, any type (E0627) 
miscellaneous durable medical equipment (DME) (E1399) DME delivery, set up, and/or dispensing service 
(A9901) and sales tax (S9999) purchased June 26, 2023. 
 
You asked the Plan to reimburse you for the lift chair and related expenses. You say that you are requesting 
reimbursement for the lift chair. Due to your medical conditions, it is imperative the lift chair is as comfortable 
as possible. The Plan denied your request. The Plan says the durable medical equipment was purchased from a 
supplier who is not enrolled and certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for a seat lift mechanism, electric, 
any type (E0627) miscellaneous durable medical equipment (DME) (E1399) DME delivery, set up, and/or 
dispensing service (A9901) and sales tax (S9999) purchased June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT testing (81455) provided on August 5, 2023. 
 
You asked the Plan to pay for the Tempus xT testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says this is not an approved test for the enrollee's 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS testing is only covered under certain 
medical indications. 
 
We find that the panel testing has not been FDA approved or cleared as a companion diagnostic. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the Tempus xT testing (81455) provided on August 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 25, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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 May 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay on September 8, 
2023, to September 11, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you did not request a 
private room. 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 $370 
copayment per day per admit for days 1-5 and a $0 copayment per day per admit for days 6-90 for inpatient 
hospital care. For the stay there was a $1,167.15 cost share. The claim was adjusted to remove the $67.15 cost 
share. For the service it's $1,167.15 - $67.15 = $1,100. Therefore, results in the total cost sharing amount of 
$1,100. You have been asked to pay a $1,100 cost share for the inpatient hospital stay. This item/service falls within the 
inpatient hospital 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. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient 
hospital stay on September 8, 2023, to September 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 08, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was 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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 August 08, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection services provided on July 17, 
2023. 
 
You asked the Plan to waive the coinsurance for the injection services. You say that you have not been charged 
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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the injection services. 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. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the injection services provided on July 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the MRI of the pelvis provided by an out-
of-network provider on September 21, 2023. 
 
You asked the Plan to waive the deductible for the MRI. You say that you need this bill written off. 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 $500 deductible which applies to the MRI. 
 
You have been asked to pay a $343.78 deductible for the MRI. 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 $500 
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 September 21, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for the MRI of the pelvis provided 
by an out-of-network provider on September 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the residence visit services provided on September 19, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the residence visit services. You say that you provided medically necessary care 
to the enrollee and should not be penalized. The Plan denied your request. The Plan says the services do not 
meet the criteria for approval. 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 had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item/service at issue. We found no exception that would 
require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for 
the residence visit services provided on September 19, 2023, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on August 
8, 2023. 
 
You asked the Plan to pay for the ED services. You say that per your information, the state allows the provider 
to perform all kinds of services in case of emergency. You say please review the attached records and reprocess 
the claim for payment. The Plan denied your request. The Plan says Medicare payment cannot be made to this 
type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
 We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on August 8, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
September 20, 2023. 
 
You asked the Plan to pay for the ED services. The Plan denied your request. The Plan says Medicare payment 
cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on September 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the Kinetic Impact sandals purchased with a 
supplemental benefit on January 24, 2023. 
 
You asked the Plan to reimburse you for the sandals. You say that you wore these shoes for a ten-day trip. You 
say that you were climbing stairs, walking long distances, and getting off and on boats and buses. You also say 
that you feel you should be reimbursed for the sandals. The Plan denied your request. The Plan says the sandals 
are not included in the services covered under the supplemental benefit. 
 
Medicare generally does not cover items or services primarily for comfort, cosmetic, or daily maintenance. 
However, the Plan offers a supplemental benefit that exceeds Medicare coverage. For that reason, the Plans 
coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the sandals are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the Kinetic 
Impact sandals purchased with a supplemental benefit on January 24, 2023.