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

 
We decided that the Plan does not have to pay for the genetic testing provided on March 21, 2023, billed with 
codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81209, and 81314. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the 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 
March 21, 2023, billed with codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81209, and 81314.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on May 
05, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you were not treated by 
the provider on this date. 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 physician/practitioner services. 
 
You have been asked to pay a $40 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner 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 medical records show you were seen by the provider on May 5, 2023. 
Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit 
provided on May 05, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room (ER) visit (87637, 87880, 99283) 
provided on June 4, 2023. 
 
You asked the Plan to pay for the ER visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as the rendering provider 
is not enrolled 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 pay for an emergency room (ER) visit (87637, 
87880, 99283) provided on June 4, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on May 18, 2023, to June 01, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you were never 
advised there would be a copayment for the services provided. 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 each physical therapy (PT) visit. 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 copayment you owe is $200 for PT services ($40 per visit x 5 
visits = $200). Therefore, we decided that the Plan does not have to waive the copayment for each physical 
therapy (PT) visit provided on May 18, 2023, to June 01, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ustekinumab quantitation with antibodies (USTEK) 
testing rendered on April 20, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
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. The file does not contain any documentation to support that the 
testing is the standard of care for the enrollee's condition. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the ustekinumab quantitation with antibodies (USTEK) testing rendered on April 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B pharmacy drugs, supplies and 
implant services on November 15, 2022, to November 17, 2022.  
 You asked the Plan to waive the coinsurance for Part B pharmacy drugs, supplies and implant services. You 
say that you should only be liable for the surgical copayment and not the coinsurance that was applied to the 
claim. 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% 
coinsurance for out-of-network covered Medicare Part B drugs, including chemotherapy drugs. Covered drugs 
include drugs that usually aren't self-administered by the patient and are injected or infused while you are 
getting physician, hospital outpatient, or ambulatory surgical center services. You must pay 20% coinsurance 
for out-of-network Medicare covered therapeutic radiology services. Covered services include but are not 
limited to surgical supplies. You must 20% coinsurance for out-of-network for Medicare-covered prosthetic 
device and related supplies. Devices (other than dental) that replace all or part of a body part or function. These 
include but are not limited to colostomy bags and supplies directly related to colostomy care, pacemakers, 
braces, prosthetic shoes, artificial limbs, and breast prostheses (including a surgical brassiere after a 
mastectomy). Includes certain supplies related to prosthetic devices, and repair and/or replacement of prosthetic 
devices. The plan paid in the amount of $19,252.43 and applied 20% coinsurance in the amount of $2473.53. 
Therefore, results in total cost sharing amount of $2,475.43. 
 
You have been asked to pay a 20% coinsurance for Part B pharmacy drugs, a 20% coinsurance for supplies and 
a 20% coinsurance for implant services. This item/service falls within the Medicare Part B prescription drugs, 
outpatient diagnostic tests and therapeutic services and supplies and prosthetic devices 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 Part B pharmacy drugs, 
supplies and implant services on November 15, 2022, to November 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary, and the enrollee's needs can be met at a lower 
level of care such as a skilled nursing facility, home with home health services, or home with outpatient 
therapy.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
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 pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable and does not need physical medicine and 
rehabilitation (PMR) physician's supervision 3 times a week in an IRF. No acute rehab nursing needs 
documented. At the current functional mobility and ADL level, the enrollee does not need intensive therapies 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an 
IRF. Document did not support necessity for admission to an IRF. The complexity of the enrollee's medical, 
rehab, and nursing needs (combined complexity) was not appropriate for acute hospital inpatient rehab stay 
with an interdisciplinary approach to rehabilitative care. The enrollee's rehab needs can be safely provided in an 
alternate and low intensity setting such as in-home with services.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drug injections provided on 
February 23, 2023, to June 08, 2023. 
 
You asked the Plan to waive the coinsurance for chemotherapy drug injections. You say that you are unable to 
afford 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 chemotherapy drug injections. 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 you owe is $5,248.57, which is 20% of the allowed amount for 
Medicare Part B chemotherapy drug injections ($26,242.89 allowed x 20% = $5,248.57). Therefore, we 
decided that the Plan does not have to waive the coinsurance for chemotherapy drug injections provided on 
February 23, 2023, to June 08, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on April 23, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with 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 $260 
copayment for ambulance services. 
 
You have been asked to pay a $260 copayment for ambulance services. 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 ambulance services 
provided on April 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on May 23, 
2023. 
 
You asked the Plan to pay for an office visit and related services. 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 an office visit and 
related services provided on May 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H0011 billed for date of service January 5, 
2023. 
 
You asked the Plan to pay for procedure code H0011. 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 H0011 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code H0011 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code H0011 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H0011 billed for date of service January 5, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on April 17, 2023, to May 15, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you were never 
advised there would be a copayment for the services provided. 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 each physical therapy (PT) visit. 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 copayment you owe is $160 for PT services ($40 per visit x 4 
visits = $160). Therefore, we decided that the Plan does not have to waive the copayment for each physical 
therapy (PT) visit provided on April 17, 2023, to May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for annual wellness visit and laboratory services provided on 
July 01, 2022. 
 
You asked the Plan to pay for annual wellness visit and laboratory services. You say that the services 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 annual wellness visit 
and laboratory services provided on July 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the primary care office visit provided on 
June 15, 2023. 
 
You asked the Plan to waive the deductible for the primary care office visit. You say that you are requesting 
reconsideration of the deductible amount. 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 $226 deductible which applies to physician/practitioner services. 
Your contract with the Plan also says that you must pay a $20 copayment after meeting the deductible for 
primary care provider office visits. 
 You have been asked to pay $125.30 towards the deductible. The item or service you asked the Plan to waive 
the deductible for falls within the physician/practitioner services benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $226 deductible which applies to 
physician/practitioner services. This cost sharing is a contractual obligation that had not been met at the time 
the primary care office visit was received on June 15, 2023. Therefore, we decided that the Plan does not have 
to waive the deductible for the primary care office visit provided on June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on April 12, 2023. 
 
You asked the Plan to pay for the podiatry services. You say that you thought authorization had been obtained. 
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 podiatry services 
provided on April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular ultrasound provided on June 15, 2023. 
 
You asked the Plan to pay for the vascular ultrasound. You say that the enrollee is using their out-of-network 
benefits. 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 vascular ultrasound 
provided on June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on May 02, 2023. 
 
You asked the Plan to pay for the pathology services. You say that the specimen was sent to your facility by the 
provider. 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 pathology services 
provided on May 02, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable oxygen concentrator provided on March 10, 2023, 
to March 11, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for a portable oxygen concentrator. You say that when you made you r purchase it 
was your understanding that the Plan would not assist you with the expense. The Plan denied your request. The 
Plan says that a portable oxygen concentrator is available in network. 
 
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 a portable oxygen concentrator provided on March 
10, 2023, to March 11, 2023, by an out-of-network (OON) provider.