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

 
We decided that the Plan does not have to pay for the chiropractic visits provided on September 11, 2023, to 
September 18, 2023. 
 
You asked the Plan to pay for the chiropractic visits. You say that you did not know the visits would not be 
covered and you are asking that the Plan reconsider the payment. 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 chiropractic visits 
provided on September 11, 2023, to September 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a wound vac and supplies provided on 
September 20, 2023. 
 
You asked the Plan to waive the coinsurance for a wound vac and supplies. You say that you were never told 
that you would have to pay for this so you feel this should be waived. 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 nd related supplies. 
 
You have been asked to pay 20% coinsurance for a wound vac and supplies. This item/service falls within the 
durable medical equipment nd 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 $327.79 which is 20% coinsurance of 
the allowed amount for these items. Therefore, we decided that the Plan does not have to waive the coinsurance 
for a wound vac and supplies provided on September 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair.  
 
You asked the Plan to pay for a shower chair. You say that you have provided documentation to support 
payment. The Plan denied your request. The Plan says this item is not covered by Medicare. The Plan must 
follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily 
medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers 
coverage of this item. Therefore, we decided that the Plan does not have to pay for a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the removal and replacement of 
implantable defibrillator provided on September 11, 2023. 
 
You asked the Plan to waive the coinsurance for the removal and replacement of implantable defibrillator. You 
say that you think that the cost sharing is too high. 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 5% 
coinsurance for each Medicarecovered outpatient surgery at a hospital outpatient facility. 
 
You have been asked to pay 5% coinsurance for the removal and replacement of implantable defibrillator. This item/service falls within the each Medicarecovered outpatient surgery at a hospital outpatient facility 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 $1,110.45 ($22,209.07 allowed amount x 5% = $1,110.45). Therefore, we decided that the Plan does not 
have to waive the coinsurance for the removal and replacement of implantable defibrillator provided on 
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 22, 2023, to 
August 29, 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on August 22, 2023, to August 29, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the myocardial perfusion imaging on July 7, 
2023.  
 You asked the Plan to waive the cost share for the myocardial perfusion imaging. You say that you would like 
the claim to be reprocessed and the $45 copayment to be all that is required for the member responsibility. 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 Medicare Part B Covered Drugs at primary care provider's (PCP) office. You must pay a $175 
copayment for advanced imaging services at outpatient hospital. The provier billed in the amount of $428 and 
the allowed amount is $10. For the service it's $10 x 20% = $2.00. For the service it's $350 + $2 + $175 = 
$527. Therefore, results in the total cost sharing amount of $527. 
 
You have been asked to pay a $527 cost share for the myocardial perfusion imaging. This item/service falls 
within the Medicare Part B prescription drugs and 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. Therefore, we decided that the Plan does not have to waive the cost share for the myocardial perfusion 
imaging on July 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 67500 billed for date of service August 21, 
2023.  
 
You asked the Plan to pay for procedure code 67500. You say that this procedure needed anesthesia. The Plan 
denied your request. The Plan says payment for code 67500 is bundled into payment for code 00145. 
 
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, we have confirmed that code 67500 is a column two code to column one code 00145 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 67500 billed for date of service August 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic panel provided on June 8, 2023. 
 
You asked the Plan to pay for the GeneSight Psychotropic panel. 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 GeneSight Psychotropic testing is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the GeneSight Psychotropic panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the GeneSight Psychotropic panel provided on June 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fungal infection polymerase chain reaction (PCR) panel 
provided on October 13, 2022, and billed with codes 87801, 87798, and 87481. 
 
You asked the Plan to pay for the fungal infection PCR panel. 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 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 fungal infection polymerase chain reaction (PCR) panel provided on October 
13, 2022, and billed with codes 87801, 87798, and 87481.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for April 14, 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 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 J96.21 has an Excludes1 note in relation to R06.02. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99285 billed for April 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the esophagogastroduodenoscopy and 
esophagus dilation provided on September 5, 2023. 
 
You asked the Plan to reduce the cost share for the esophagogastroduodenoscopy and esophagus dilation. You 
say that you feel the cost share amount is too excessive. 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 $20% coinsurance, a $525 deductible which applies to Outpatient 
hospital services.  
 You have been asked to pay a total of $537.55 for the outpatient surgery. This item/service falls within the 
Outpatient hospital services benefit category.  
 
The allowed amount for the esophagogastroduodenoscopy was $830.44, which $458.87 was applied towards 
your deductible. This left a balance of $371.57. 
 
The balance for the esophagogastroduodenoscopy of $371.57, which the 10% coinsurance has been applied. 
This left you with a coinsurance of $37.16. 
 
The allowed amount for the dilation of the esophagus was $415.22, which the 10% coinsurance had been 
applied. This left you with a coinsurance of $41.52. 
 
This means that you have been asked to pay the correct amount based on your contract with the Plan ($458.87 
+ $37.16 + 41.52 = $537.55). 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 the esophagogastroduodenoscopy and esophagus 
dilation provided on September 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit services provided on June 8, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the office visit services. You say that the claim should be reprocessed and paid. 
The Plan denied your request. The Plan says the services were not urgent or emergent in nature and there was 
no valid authorization for the services. 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 the office visit services provided on June 8, 2023, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical colonoscopy and the hospital outpatient visit 
provided on October 06, 2023. 
 
You asked the Plan to pay for the cervical colonoscopy and the hospital outpatient visit. You say that you are 
requesting reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the cervical colonoscopy 
and the hospital outpatient visit provided on October 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 26, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care provided on August 26, 2023. 
 
You asked the Plan to pay for observation care. You say that you are requesting reconsideration for 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 observation care 
provided on August 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 22, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair.  
 
You asked the Plan to pay for a shower chair. You say that you needed this item to shower safely after surgery. 
The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 4, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you have submitted medical records to support 
payment. The Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 4, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on August 01, 2023, to August 15, 
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 August 01, 2023, to August 15, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospice services rendered from April 1, 2023, to April 
30, 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. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospice services rendered from April 1, 2023, to April 30, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cataract surgery provided on June 7, 
2023, and June 23, 2023. 
 
You asked the Plan to waive the copayment for the cataract surgery. You say that you called your insurance 
ahead of time and was told you would have no copayment for the surgery. 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 $300 
copayment for in-network surgery services at an ambulatory surgical center. You have been asked to pay a total of $538.06 for the cataract surgery ($269.03/visit x 2 = $538.06). This 
item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers benefit category. You were billed $269.03 per visit which is less than the standard 
$300 per visit copayment. 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 cataract surgery 
provided on June 7, 2023, and June 23, 2023.