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

 
We decided that the Plan does not have to waive the copayment for diagnostic radiology services provided on 
May 19, 2020. 
 
You asked the Plan to waive the copayment for diagnostic radiology services. You say that you disagree with 
the copayment. The Plan denied your request. The Plan says the copayment you are being charged is correct. 
 
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 $250 
copayment for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay $244.97, which is less than your copayment for diagnostic radiology services. 
Diagnostic radiology services 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 diagnostic radiology services 
provided on May 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on May 27, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that your cyst was inflamed and you were 150 miles 
away and could not get prior authorization. The Plan denied your request. The Plan says prior authorization 
was not obtained. The Plan says that these services are not emergent. 
 
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 May 27, 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 continuous glucose monitoring system provided on April 
29, 2020. 
 
You asked the Plan to pay for a continuous glucose monitoring system. You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says the enrollee did not meet criteria for a CGM. 
 
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 record does not contain relevant medical records which support 
medical necessity for the supplies provided in this case. Based on this information, we decided that Medicare 
rules for coverage of a continuous glucose monitoring system have not been met. The record shows that the 
Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that 
the Plan does not have to pay for the continuous glucose monitoring system provided on April 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wheelchair accessories (K0108, E1004) provided January 21, 
2020. 
 
You asked the Plan to pay for the wheelchair accessories. You say that the items were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the services billed. 
 
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 code K0108, E1004 is not supported in the medical record. Specifically, the shipping 
invoices provided are not legible. The patient's name and service dates cannot be determined. Based on this 
information, we decided that Medicare rules for coverage of the wheelchair accessories have not been met. 
Therefore, we decided that the Plan does not have to pay for wheelchair accessories (K0108, E1004) provided 
January 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anterior resin-based composite (D2331) and two 
posterior resin-based composites (D2391 x2) provided on May 19, 2020. 
 
You asked the Plan to pay for the resin-based composites. You say that the pre-treatment plan was done in 
2019, and you still had benefits left in 2019 from the annual maximum. You also say that since the approval 
was processed in 2020, you have gone over the available 2020 benefit maximum by $450. The Plan denied 
your request. The Plan says you have exceeded the $2,000 annual maximum payout for dental services for the 
2020 plan year. 
 
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 Plan offers a $2,000 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit while processing this claim for the May 19, 2020 date of service, and your annual maximum 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the anterior resin-
based composite (D2331) and two posterior resin-based composites (D2391 x2) provided on May 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
October 19, 2019. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine the optimal treatment pathway for the enrollee. 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 CGP testing must be billed with CPT code 81479 
for date of service October 19, 2019.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. 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 comprehensive genomic profile (CGP) testing provided on 
October 19, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
You asked the Plan to waive the coinsurance for drugs and administration services. You say that you were told 
that these drugs would have no cost, and you are on a fixed income. The Plan says that the coinsurance amount 
you are being charged is correct. 
 
We decided that the Plan has to waive the coinsurance for drugs and administration services in the 
amount of $1,371.01, applied to codes J1745 and 96413.  
 
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 enrollees must pay 20% coinsurance for Part B drugs and the administration of 
these drugs.  
 
The Plan says you must pay a coinsurance amount of $1,364.93 for drug code J1745 and a coinsurance amount 
of $6.08 for administration code 96413. According to the Explanation of Benefits submitted by the Plan, these 
codes each have an allowed amount of $0. Coinsurance is determined based on the allowed amount of each 
applicable line item of a claim. Therefore, based on the Plan contract, you cannot be asked to pay more than $0 
coinsurance for these drugs and administration charges. Therefore, we decided that the Plan has to waive the 
$1,371.01 coinsurance amount for drugs and administration services.  
 
We also decided that the Plan does not have to waive the coinsurance for drugs and administration 
services in the amount of $88, applied to codes J1745 and 96415. 
 
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 drugs and administration services. The total allowed amount of these codes is $440, resulting in 
a coinsurance obligation of $88. Therefore, we decided that the Plan does not have to waive the coinsurance for 
drugs and administration services. 
 
Therefore, we decided that the Plan has to reduce your total cost-sharing obligation for this claim from 
$1,459.01 to $88. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided during the 
revascularization services. 
 
You asked the Plan to pay for the assistant surgeon 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 payable. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services 
provided during the revascularization services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on September 15, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for podiatry services. 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 by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 podiatry services provided on September 15, 2019 
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says needs can be met in a lower level of care, such as IRF or even SNF. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short term acute 
care hospitals. In this case, ongoing care needs include intravenous antifungal, nephrostomy tube care, 
surveillance laboratory studies, tube feeding, and therapy services. The documentation does not support that the 
enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is 
currently receiving care. There are no required medical services identified that are available at the LTACH, that 
are not available at the current health care setting being offered by the health plan. Consequently, the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee at this time. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) of the 
upper right, upper left, lower right, and lower left quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says the 
services are not medically necessary. 
 
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. The Plan covers the scalings 
and planings when the services are medically necessary and reasonable.  
 
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 the scalings and planings. Our reviewer 
says that the periodontal scalings and root planings do not meet coverage criteria. Our physician reviewer 
found the provided x-rays reveal an obvious bony defect between tooth #'s 14 & #15, but minimal bone 
changes in the other areas of the mouth.  There is arguably some upper anterior bone loss, however there are no 
abnormal pocket readings in the areas involved. Our reviewer found that the posterior areas which are noted on 
the supplied periodontal charting as being above the normal range do not show any significant bone loss. No 
one quadrant shows four or more affected teeth that also have notable bone loss. Our physician reviewer also 
found that there are not a minimum of four affected teeth in a quadrant, which requires there be loss of bone 
support as well as pocket depth readings in excess of normal. 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the scalings and planings have not been met. Therefore, we decided that the 
Plan does not have to pre-approve periodontal scalings and root planings (D4341) of the upper right, upper left, 
lower right, and lower left quadrants.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you fell because you were dehydrated and 
did not want to go to the hospital. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 7, 2020 to June 9, 2020. The ambulance 
benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the 
services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on April 20, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 20, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on April 
20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat 
exchanger services provided on March 13, 2020. 
 
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. 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 separately payable. 
 
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 99190 is assembly and operation of pump with 
oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour. 
 
We find that CPT code 99190 is not supported in the medical record. Specifically, these services were received 
in the facility during inpatient hospitalization. Payment for this service is included in the Part A DRG payment 
to the facility. Based on this information, we decided that Medicare rules for coverage of the assembly and 
operation of pump with oxygenator or heat exchanger have not been met. Therefore, we decided that the Plan 
does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services 
provided on March 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the cost sharing for the therapeutic exercises (97110) provided 
on March 17, 2020. 
 
You asked the Plan to adjust the cost sharing. 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 service 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 4% of 
the cost for each Medicare-covered outpatient rehabilitation service visit. Additionally, a $150 annual 
deductible must be met before the Plan pays their share for Medicare covered services provided.  
 
You have been asked to pay $80.90 for the outpatient rehabilitation service provided. This amount is the Plan 
allowed amount, which has been applied to your annual deductible responsibility of $150. The annual 
deductible must be met before the Plan will pay its share for your Medicare covered services provided. At this 
time, you have met $122.29 of your annual deductible, which includes this service provided. 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 therapeutic exercises (97110) provided on March 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 molecular pathology genomic profiling 
provided to the enrollee on July 5, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic 
profiling for bladder cancer. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for Guardant360 molecular pathology genomic profiling provided to the enrollee on July 5, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on May 18, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that this service should have been 
covered. The Plan denied your request. The Plan says the copayment you are being charged is correct. 
 
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 $235 
copayment for each covered diagnostic procedure or test at a network outpatient facility.  
 
You have been asked to pay $224.08, which is less than your copayment for an ultrasound. An ultrasound 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 ultrasound provided on May 18, 2020.