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

 
We decided that the Plan does not have to pay for the Esophagogastroduodenoscopy provided on December 10, 
2019. 
 
You asked the Plan to pay for Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon 
dilation of esophagus (less than 30 mm diameter) (43249-51). You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says the documentation submitted did not include documentation of 
Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less 
than 30 mm diameter) therefore the billed service cannot be verified. 
 
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, the CPT Code Manual definition of code 43249-51 is Esophagogastroduodenoscopy, flexible, 
transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter).  
 
We find that CPT code 43249-51 is not supported in the medical record. Specifically, there are no procedure 
notes in the record for an Esophagogastroduodenoscopy. Based on this information, we decided that Medicare 
rules for coverage of Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation 
of esophagus (less than 30 mm diameter) (43249-51) have not been met. Therefore, we decided that the Plan 
does not have to pay for the Esophagogastroduodenoscopy provided on December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic pulpotomy (D3220) provided on April 1, 
2020. 
 
You asked the Plan to pay for the therapeutic pulpotomy (D3220). You say that this was an emergency visit for 
severe tooth pain. You say that the emergency service should be covered. The Plan denied your request. The 
Plan says the service is 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, 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 
therapeutic pulpotomy (D3220) provided on April 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation provided on March 29, 2020. 
 
You asked the Plan to pay for the transportation. The Plan denied your request. The Plan says ambulance 
transport was not medically necessary. 
 
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 the transportation. Our reviewer says that the 
requested ambulance transportation was not medically reasonable and necessary. Our physician reviewer found 
that the documentation does not support that other means of transport, such as a wheelchair van, were 
contraindicated for the enrollee. The documentation also does not support that the enrollee needed the expertise 
and equipment found only in an ambulance for safe transport. The enrollee would have been able to have been 
safely transported via other means without special staff or equipment. The documentation does not support that 
the ambulance transportation on March 29, 2020, was medically reasonable and necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the transportation have not been met. Therefore, we decided that the Plan does 
not have to pay for the ambulance transportation provided on March 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DME provided from April 10, 2020 to April 13, 2020. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says that the Plan requires 
utilization of network providers when possible and available, and requires authorization for certain services. No 
medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been 
documented. 
 
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 did not pre-approve the 
DME. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for DME provided from April 10, 2020 to April 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 28, 2019. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on October 28, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services 
you received from March 1, 2020 through March 24, 2020. 
 
You asked the Plan to waive the copayment for the SNF services. You say that you thought your health plan 
would cover these services completely. The Plan denied your request. The Plan says you were charged this 
copayment 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 [$0 for 
days 1-20 in a SNF, and $50 per day for days 21-100 in a SNF. 
 
Records show that you were admitted to the SNF on February 11, 2020.  You did not leave the facility until 
March 24, 2020.  You were in the facility for a total of 42 days. You were not charged any cost sharing for the 
first 20 days.  For the remaining 22 days, the Plan charged you a copayment of $50 per day, for a total of 
$1,100. This is the exact amount you have been asked to pay for the SNF 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 skilled nursing facility (SNF) services you received from March 1, 2020 
through March 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on September 25, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the member's primary care physician did not refer these 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 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 lab work provided on September 25, 2019 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 nursing facility care (99309) provided on December 12, 
2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON nursing facility care. You say that this was a medically necessary service 
provided in good faith. The Plan denied your request. The Plan says this service was not authorized. 
 
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 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 nursing facility care (99309) provided on 
December 12, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the cost sharing for the intravitreal eye drug injection (67028) 
and the unclassified drug (J3490) provided on May 8, 2020. 
 
You asked the Plan to adjust the cost sharing 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 the cost sharing 
has been applied correctly to the services provided. 
 
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 drugs. Additionally, enrollees must pay a $20 copayment for visits to 
specialists. Medicare Part B drugs are subject to the 20% coinsurance plus any applicable copayment.  
 
You have been asked to pay $65 ($225 allowed amount x 20% coinsurance=$45 + $20 copayment) for the 
Medicare Part B drugs provided and the visit to a specialist. 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 adjust the cost sharing 
for the intravitreal eye drug injection (67028) and the unclassified drug (J3490) provided on  
May 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on April 8, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for an x-ray. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 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 an x-ray provided on April 8, 2020 by an out of 
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) with sleeves 
provided on February 11, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the OON PCD. You say that no pre-certification is required based on your 
contract with the Plan. The Plan denied your request. The Plan says there is no contract with this Plan and this 
provider is out of network. As such, this would require prior authorization as there are network providers 
available to provide the denied equipment. 
 
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 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 pneumatic compression device (PCD) with 
sleeves provided on February 11, 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  81225, 81226, 81227, 81230, 
81231, 81240, 81241, 81328, 81335, 81355, 81232, 81283, and 81408 provided on February 19, 2020. 
 
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 were billed incorrectly. 
 
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 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81328, 81335, 81355, 81232, 
81283, and 81408 are not supported in the medical record. Specifically, the place of service on the CMS-1500 
form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim 
form indicates the laboratory specimen was obtained in a laboratory, place of service 81, however, the 
submitted medical documentation and/or claim history indicates that the specimen was obtained in an office 
setting place of service 11. 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  81225, 81226, 81227, 81230, 81231, 81240, 81241, 81328, 81335, 81355, 81232, 
81283, and 81408 provided on February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on February 25, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that this should be covered. You say that you would 
like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not 
obtained. The Plan says that the member's primary care physician did not refer these 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 has network providers 
available who can provide 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 physician services provided on February 25, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for skilled nursing facility (SNF) services 
you received from March 1, 2020 through April 13, 2020. 
 
You asked the Plan to reduce the copayments for the SNF services. You say that the amount you are being 
charged is too high. The Plan denied your request. The Plan says you were charged these copayments 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 [$0 for 
days 1-20 and $160 per day for days 21-100 for SNF services.  Your contract also says that your maximum out-
of-pocket amount for 2020 is $5,500. 
 
Records show that you were in a SNF from February 21-April 13.  For the first 20 days of this stay (February 
21-March 11), you were charged $0 per day in accordance with your Evidence of Coverage.  From March 11- 
March 31, (a total of 20 days), you were charged $160 per day in accordance with your Evidence of Coverage 
(for a total of $3,200). Your SNF stay continued until April 13.  However, after March 31, you had already paid 
a total of $5275.66 towards your total out-of-pocket amount for the year with your SNF stay and other medical 
services you received in 2020.  Therefore, when the claim for the remainder of your SNF stay in April was 
submitted to the Plan, only $224.34 remained on your maximum out-of-pocket amount.  That is why you were 
only charged $224.34 for the remaining SNF services in April instead of the full $160 per day. 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 reduce the copayments for skilled nursing facility (SNF) services you received from March 1, 
2020 through April 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 9, 2020. 
 
You asked the Plan to pay for lab tests. You say that this testing was ordered by the enrollee's treating 
physician. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because this testing was ordered by telemedicine which is a Medicare prohibited action. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for laboratory testing provided 
on January 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960), wrist hand 
orthosis (L3916), knee orthosis (L1851), lumbar sacral orthosis (L0650), ankle orthosis (L1971), heel stabilizer 
(L3170) and additions (L2397, L2385, L2820 and L2830) provided on April 29, 2020. 
 
You asked the Plan to pay for the orthoses and additions. You say that you would like reconsideration because 
these supplies are medically necessary. The Plan denied your request. The Plan says the reasonableness of the 
provided durable medical equipment is not established. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand 
orthosis (L3960), wrist hand orthosis (L3916), knee orthosis (L1851), lumbar sacral orthosis (L0650), ankle 
orthosis (L1971), heel stabilizer (L3170) and additions (L2397, L2385, L2820 and L2830) provided on April 
29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on May 20, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for outpatient services. You say that you were told that prior authorization was not 
required by the referring provider. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
these services could have been provided 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 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 outpatient services provided on May 20, 2020 by 
an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT professional component. 
 
You asked the Plan to pay for CT (72131-26). You say that the Plan should pay this claim. The Plan denied 
your request. The Plan says this is a duplicate claim already paid. 
 
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, the service was previously paid to a separate provider for the same enrollee on the same date of 
service. The claim submitted does not contain a modifier or indicator that these services were separate and 
distinct from the previous claim. Based on this information, we decided that Medicare rules for coverage of CT 
(72131-26) have not been met. Therefore, we decided that the Plan does not have to pay for the Computed 
Tomography, lumbar spine; without contrast material, professional component provided on March 21, 2020.