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

 
We decided that the Plan does not have to waive the copayment for an X-ray provided on May 19, 2020. 
 
You asked the Plan to waive the copayment for an X-ray. You say that you disagree with the charges because 
they should be included in a post-surgical follow-up. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct amount. 
 
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 $30 
copayment for X-rays.  
 
You have been asked to pay the allowed amount of $29.82, which is less than the $30 copayment for an X-ray. 
An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an X-ray provided on May 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 16, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says the services are 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 has network providers 
available who can provide the lab services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided 
that the Plan does not have to pay for the lab services provided on August 16, 2019 by an out of network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incomplete endodontic therapy (D3332) provided on 
May 11, 2020. 
 
You asked the Plan to pay for the incomplete endodontic therapy. You say that you have dental coverage for 
endodontic treatment under the platinum dental rider. The Plan denied your request. The Plan says this service 
is not a covered benefit under your dental plan. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
incomplete endodontic therapy (D3332) provided on May 11, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the hospital outpatient clinic visit (G0463), magnetic resonance 
imaging (MRI) of the brain (70553), laboratory service (82565), and the Gadobutrol injection (A9585) 
provided on January 7, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the services were rendered by an out of 
network provider, without prior authorization. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request.  Therefore, we decided that the Plan has to pay for the hospital outpatient clinic 
visit (G0463), magnetic resonance imaging (MRI) of the brain (70553), laboratory service (82565), and the 
Gadobutrol injection (A9585) provided on January 7, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two osseous surgeries (D4260 x2) provided on March 12, 
2020. 
 
You asked the Plan to pay for the osseous surgeries. You say that these services were already approved by the 
Plan. You also say that these procedures were delayed because your provider closed his practice twice, which is 
why these services were rendered in March. The Plan denied your request. The Plan says this service is not 
covered under your plan benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The approval letter for these services clearly states that the approved 
amount is subject to the terms of your coverage in effect on the date of receipt, and may change if the contract 
or the proposed treatment plan changes. The Plan's 2020 Evidence of Coverage does not list osseous surgery 
(D4260) as a covered benefit. Therefore, we decided that the Plan does not have to pay for the two osseous 
surgeries (D4260 x2) provided on March 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral evaluation and x-rays provided on May 29, 2020. 
 
You asked the Plan to pay for the oral evaluation and x-rays. You say that the new dentist does not participate 
with the plan, but you couldn't find any other dentists. The Plan denied your request. The Plan says payment 
cannot be issued for services performed by a provider who has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the oral evaluation and x-rays provided on May 29, 2020.  
 
Your complaint about your dissatisfaction with the care given 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a stay at an inpatient rehabilitation facility 
from January 14 to January 28, 2020. 
 
You asked the Plan to waive the copayment for a stay at an inpatient rehabilitation facility. You say that you 
are being incorrectly charged as though for an inpatient hospital stay. The Plan denied your request. The Plan 
says the correct copayment was applied. 
 
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 $325 
copayment for each day of days 1 to 5 of each Medicare-covered inpatient hospital admission/stay, including 
inpatient rehabilitation.  
 
You have been asked to pay $1,625, or a $325 copayment for each day of days 1 to 5, for a stay at an inpatient 
rehabilitation facility. A stay at an inpatient rehabilitation facility 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 a stay at an inpatient 
rehabilitation facility from January 14 to January 28, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visits (99348 and 99350) provided on August 22, 
2019. 
 
You asked the Plan to pay for home visits. You say that this was medically necessary. The Plan denied your 
request. The Plan says these codes are not appropriate for visits by a Licensed Vocational Nurse (LVN). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  A home visit cannot be billed by a physician 
unless the physician was actually present in the beneficiary?s home. 
 
We find that CPT codes 99348 and 99350 are not supported in the medical record.  Specifically, the records do 
not support that the billing physician was present in the enrollees home. The records indicate that the visit in 
question was a skilled nursing visit performed by a LVN. Based on this information, we decided that Medicare 
rules for coverage of home visits have not been met. Therefore, we decided that the Plan does not have to pay 
for home visits (99348 and 99350) provided on August 22, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on March 14, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 must be billed with CPT code 
81479 for date of service March 14, 2020.  
 
We looked at the file and Medicare rules. 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 
Guardant360 testing provided on March 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) 
provided to the enrollee on May 2, 2019. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the is no objective documentation of joint laxity. 
 
The Plan must follow Medicare rules. Under Medicare rules, your request is not medically necessary because 
your medical records fail to document objective knee joint instability. Therefore, we decided that the Plan does 
not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on May 2, 
2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0429) provided 
on January 25, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the copayment should be 
waived because you were sent to the emergency room by ambulance against your will. The Plan denied your 
request. The Plan says you were charged this cost sharing 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 $350 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $350 for these 
services. 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 ambulance services (A0429) provided on 
January 25, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health physician office visits provided September 
24, 2019 to March 2, 2020. 
 
You asked the Plan to pay for the office visits. You say that you have made no changed to your insurance or 
billing practices and have opted out of Medicare since 2009. You have been paid as an out of network provider 
for years. The Plan denied your request. The Plan says the services are not covered when rendered by a 
physician who has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the mental health physician office visits provided September 24, 2019 to March 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services provided 
from February 12, 2020 to February 24, 2020. 
 
You asked the Plan to waive the copayment for inpatient rehabilitation services. You say that you were told this 
would be fully covered. The Plan denied your request. The Plan says this processed 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 $295 
copayment per day for days 1 through 6 and a $0 copayment for days 7 through 90 for inpatient hospital care.  
 
You have been asked to pay a $295 copayment per day for the first six days of inpatient rehabilitation services 
for a total of $1,770. 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 inpatient rehabilitation services 
provided from February 12, 2020 to February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 6, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you have provided medical records to justify 
payment of this claim. The Plan denied your request. The Plan says unauthorized, non-plan 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 in this case is not a network provider with the Plan. The Plan has 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 medical services provided on January 6, 2020 
by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
(CPT Code A0429) and ground mileage (CPT Code A0425) provided on February 8, 2020. 
 
You asked the Plan to pay for ambulance services. You say that the patient was transported multiple times on 
the same date of service. The Plan denied your request. The Plan says the clinical information does not support 
medical necessity for ambulance transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for ambulance services. Our physician reviewer 
found per the reviewed documentation upon ambulance arrival, the enrollee was sitting complaining of mucus 
in the back of their throat for an hour prior to arrival of emergency medical services. Physical status and vital 
signs were documented by emergency medical services as normal. The patient was hemodynamically stable 
with stable vital signs. The review has determined that the items/services at issue in this case were not 
medically reasonable or necessary. The documentation indicates that the patient could have been safely 
transported by another type of motor vehicle, possibly a van transport vehicle. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan does 
not have to pay for ambulance service, basic life support, emergency transport (CPT Code A0429) and ground 
mileage (CPT Code A0425) provided on February 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite provided on June 1, 2020. 
 
You asked the Plan to pay for the resin-based composite. You say that you have been seeing this dentist for 
decades. You say that you were not informed of the requirement of using a dentist on the preferred provider 
list. The Plan denied your request. The Plan says out-of-network dental services are not 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 Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-
based composite provided on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 7, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you were not aware that these services 
required prior authorization.  You stated that these services were medically necessary and provided in good 
faith. The Plan denied your request. The Plan says unauthorized, non-plan 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. 
 
Neither your organization nor the ordering provider is a network provider with the Plan. The Plan has 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 medical services provided on 
May 7, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 80157 and 80177 provided on 
December 16, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 80157 and 80177 are not supported in the medical record. Specifically, the 
documentation submitted did not support that Carbamazepine; free testing or Levetiracetam testing were 
performed. Blood specimen collection is by venipuncture, however, the lab requisition states a urine specimen 
was collected. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
coded 80157 and 80177 provided on December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services provided by a 
participating provider on February 11, 2020. 
 
You asked the Plan to waive the copayment for outpatient services. You say that you do not know why you are 
being charged twice. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $45 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $45 copayment for outpatient services. The correct copayment has been applied 
to the services that were provided. Outpatient services fall within the physician/practitioner services/specialist 
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 outpatient services provided by a 
participating provider on February 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation services provided on March 11, 
2020. 
 
You asked the Plan to pay for the transportation services. You say that transportation was arranged to and from 
a GI specialist. The Plan denied your request. The Plan says the ambulance service was billed for an origin or 
destination that is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for the ambulance transportation services provided on 
March 11, 2020.