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

 
We decided that the Plan does not have to waive the copayments for an orthopedic visit and injection provided 
on July 24, 2023. 
 
You asked the Plan to waive the copayments for an orthopedic visit and injection. You say that you should not 
have a copay for either of these 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 $20 
copayment for physician/practitioner services, including doctors office visits, and a $5 copayment for 
Medicare Part B drugs.  
 You have been asked to pay a $25 total copayment for an orthopedic visit and injection ($20 + $5 = $25). This 
item/service falls within the physician/practitioner services, including doctors office visits, and Medicare Part 
B 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 copayments for an orthopedic visit and 
injection provided on July 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a chinstrap provided on August 14, 2023. 
 
You asked the Plan to waive the coinsurance for a chinstrap. You say that you did not request or use this item. 
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 in-network durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for a chinstrap. This item/service falls within the in-network 
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 total amount you owe is $2.40 ($11.99 allowed amount x 20% = $2.40). Therefore, we decided that the Plan does not have to waive the coinsurance for a chinstrap 
provided on August 14, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 17, 2023, by an out-
of-network (OON) provider.  
 
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 the services were rendered by a non-participating provider. 
 
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 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 home health services provided on March 17, 2023, 
by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on July 05, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy provided 
on July 05, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 6, 2023. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. 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 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rollator (E1399). 
 
You asked the Plan to pre-approve the rollator. You say that this device is medically necessary. The Plan 
denied your request. The Plan says a walker that meets the enrollee's needs has already been approved. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have been approved for a heavy duty walker with a seat. The heavy duty walker serves 
the same purpose as the requested rollator. Therefore, we decided that the Plan does not have to pre-approve a 
rollator (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cup holder for wheelchair (K0108) and an unoccupied 
tiedown loop kit (K0108). 
 
You asked the Plan to pre-approve a cup holder for wheelchair (K0108) and an unoccupied tiedown loop kit 
(K0108). You say that the requested cup holder and unoccupied tiedown loop kit are medically necessary. The 
Plan denied your request. The Plan says the requested cup holder and unoccupied tiedown loop kit are not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    

The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a cup holder for wheelchair (K0108) and an unoccupied 
tiedown loop kit (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87653, 87481, 87798, 87641, and 87640) 
provided on August 14, 2023. 
 
You asked the Plan to pay for procedure codes 87653, 87481, 87798, 87641, and 87640. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not covered as billed. 
 
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 panel testing (87653, 87481, 87798, 87641, and 87640) provided on August 
14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the endodontic therapy, anterior tooth (excluding final 
restoration) (D3310) provided on August 9, 2023. 
 
You asked the Plan to pay more for the endodontic therapy. You say that you contacted the dental department 
with the plan prior to the procedure to ensure the treatment needed would be covered. You also say that you 
were advised the service would be covered due to only having $1,200.00 left of your yearly allowance. The 
Plan denied your request. The Plan says your benefit for the endodontic therapy, anterior tooth $2,000 dollar 
limit as partially met. 
 
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. Specifically, 
the benefit for supplemental dental coverage is limited to $2,000 annually. The records show that the Plan paid  
$55 under claim number ending in 04211 for dental services provided on February 13, 2023. The records show 
the Plan paid $315 under claim number 52039 for dental services provided on April 19, 2023. The records 
show that the Plan paid $295 under claim number ending in 54436 for date of service May 18, 2023. The 
records show the Plan paid $84 under claim number ending in 86008 for date of service June 6, 2023. The 
records show the Plan paid $61 under claim number ending in 56648 for date of service July 7, 2023. The 
records show the Plan paid $113 under claim number ending in 30854 for date of service September 15, 2023. 
The records show that the Plan paid $1,077 under claim number ending in 66299 for date of service August 9, 
2023. This was a partial payment towards the endodontic therapy in dispute. Once this partial payment was 
made, the yearly benefit maximum was reached. Therefore, we decided that the Plan does not have to pay more 
for the endodontic therapy, anterior tooth (excluding final restoration) (D3310) provided on August 9, 2023.  
 
Your complaint about how you were treated by the health plan is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on July 27, 2023. 
 
You asked the Plan to pay for the home health services. You say that requesting reconsideration of the claim 
asking to review medical records to support medical necessity of services billed. 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 home health services 
provided on July 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 22, 2023, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, and 81355. 
 
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 22, 2023, billed with codes 81225, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, and 
81355.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bolt on height adjustable push handles (K0108). 
 
You asked the Plan to pre-approve bolt on height adjustable push handles. You say that you are aware that the 
following items included in the current submission request are typically non-covered: K0180 bolt on height 
adjustable push handles. The Plan denied your request. The Plan says a wheelchair component or accessory 
that does not primarily serve a medical purpose is excluded. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bolt on height adjustable push handles have not been met. Therefore, we decided that the Plan does 
not have to pre-approve bolt on height adjustable push handles (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDX-SCC test (0315U) provided on September 
20, 2023. 
 
You asked the Plan to pay for the DecisionDX-SCC test. You say that this testing was medically necessary.   
The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process.  
 We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDX-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDX-SCC test (0315U) provided on 
September 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure 
device and supplies provided on January 31, 2022. 
 
You asked the Plan to waive the coinsurance for the continuous positive airway pressure device and supplies. 
You say that you were unaware of the cost share. 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 the continuous positive airway pressure device and supplies. 
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. Therefore, we decided that the Plan 
does not have to waive the coinsurance for the continuous positive airway pressure device and supplies 
provided on January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on June 20, 2023. 
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. 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 M54.50 has an Excludes1 note in relation to M54.42. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the office visit have not been met. Therefore, we decided that the Plan does not have to pay for 
an office visit (99213) provided on June 20, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9123 billed for date of service July 26, 
2023. 
 
You asked the Plan to pay for procedure code S9123. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 S9123 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9123 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9123 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9123 billed for date of service July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the collagenase injection drugs, and the 
injection administrations provided on July 24, 2023, and July 26, 2023. 
 
You asked the Plan to waive the cost share for the injection services. You say that you were told that the 
services would be 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 Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must 
pay a $35 copayment for provider and professional services at a specialist office. 
 
You have been asked to pay $1,119.99, which is less than 20% coinsurance of the allowed amount for each 
injection drug provided on July 24, 2023, and July 26, 2023. These items/services fall 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.  
 
You have also been asked to pay a $35 copayment for each injection administration provided on July 24, 2023, 
and July 26, 2023. These items/services fall within the physician/practitioner services, including doctor's office 
visits 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 cost share for the collagenase injection drugs, 
and the injection administrations provided on July 24, 2023, and July 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Vitamin B-12 test (82607) provided on June 2, 2023. 
 
You asked the Plan to pay for the Vitamin B-12 test. You say that the services should be covered. The Plan 
denied your request. The Plan says the service must be billed to the primary insurer first. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer.  
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the Vitamin B-12 test until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for a Vitamin B-12 test (82607) provided on June 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an acute inpatient stay provided on July 03, 
2023, to July 06, 2023. 
 
You asked the Plan to waive the copayment for an acute inpatient stay. You say that you have already paid this 
once before for the same issue. You feel you should not have to pay this 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 $395 
copayment for inpatient hospital care. 
 
You have been asked to pay a $395 copayment for an acute inpatient 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. You have been asked to pay a $395 copayment for the inpatient hospital stay. Therefore, 
we decided that the Plan does not have to waive the copayment for an acute inpatient stay provided on July 03, 
2023, to July 06, 2023.