Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first 15 minutes of deep sedation/general anesthesia and 
each subsequent 15 minute increment of deep sedation/general anesthesia provided on June 30, 2020. 
 
You asked the Plan to pay for the deep sedation/general anesthesia services. You say that you would like to 
appeal these services. The Plan denied your request. The Plan says these services are not covered. 
 
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 first 
15 minutes of deep sedation/general anesthesia and each subsequent 15 minute increment of deep 
sedation/general anesthesia provided on June 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided October 15, 2020 
to October 16, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was brought by EMS to the emergency department for treatment of 
hyperglycemia. The enrollee was admitted in guarded condition for further treatment of an acute kidney injury 
and hyperglycemia. The enrollee's treatment included electrolyte and renal function monitoring IV fluids at 150 
ml/h, glucose monitoring with insulin coverage, potassium phosphate, heparin, verapamil, and a Nephrology 
evaluation. Lisinopril was held. Nephrology diagnosed the enrollee with an acute kidney injury superimposed 
on CKD III secondary to intravascular volume depletion from hyperglycemia with recommendations to 
continue gentle hydration and a renal ultrasound. A renal ultrasound showed bilateral renal cysts. The enrollee's 
creatinine level improved to 1.51 mg/dl with treatment. The enrollee's phosphorus level was repleted and 
improved to 3.0. The enrollee's blood glucose level control improved. On October 16, 2020, after thorough 
evaluation and confirmation of hemodynamic stability with resolution of acute kidney injury, improved control 
of blood glucose and negative COMD-l9 testing the enrollee was deemed safe and stable for discharge home on 
October 16, 2020. The review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided October 15, 2020 to October 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvoya. 
 
You asked the Plan to pre-approve Genvoya. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Genvoya.  
 
Benefits for Genvoya may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99204 provided on 
 
You asked the Plan to pay for the office visit. 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. 
 
In this case, the CPT Code Manual definition of code 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting 
problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient 
and/or family. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, the documentation supports 
that the enrollee previously saw the same exact provider within the past three years. This code was 
inappropriately billed. Based on this information, we decided that Medicare rules for coverage of the office 
visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 
99204 provided on
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on August 19, 2020. 
 
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says 
prior authorization was not obtained by the provider or facility. 
 
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 
outpatient hospital services. 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 outpatient hospital services provided on August 
19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine rendered on June 3, 2020. 
 
You asked the Plan to pay for these services. You say that you thought the services would be covered. The Plan 
denied your request. The Plan says the services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to these services. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine rendered on June 3, 2020.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the 2 abutment supported crown (D6059) 
provided on February 18, 2020. 
 
You asked the Plan to reimburse you for the abutment supported crowns. You say that you want the $893 bill 
to be voided. You also say that you would like $1,400 to be refunded to you. The Plan denied your request. The 
Plan says abutment supported crowns are not listed as covered services. 
 
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 Evidence of Coverage clearly states that if you get a service not 
listed in the table, you will have to pay the full cost. Therefore, we decided that the Plan does not have to 
reimburse you for the 2 abutment supported crown (D6059) provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the services rendered from May 17, 2019 
to August 22, 2019. 
 
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the copayments were applied 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 $90 
copayment for emergency care, a $175 copayment for outpatient surgery, a $50 copayment for x-rays, a $250 
copayment per day for days 1-6 for inpatient hospital care, and a $35 copayment for specialist services. 
 
Review of the file shows that you received emergency room services on May 17, 2019 and June 12, 2019. You 
have been asked to pay a $90 copayment per date of service for these services, for a total of $180. These 
services fall within the emergency care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan.  
 
The file shows that you received outpatient surgery on August 5, 2019. You have been asked to pay a $175 
copayment for these services. These services fall within the outpatient surgery benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan.  
 
The file shows that you received an x-ray on August 7, 2019. You have been asked to pay a $50 copayment for 
these services. These services fall within the x-rays benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan.  
 
The file shows that you received inpatient hospital services from August 13, 2019 to August 19, 2019. You 
have been asked to pay a $250 copayment per day for days 1-6 for these services, for a total of $1,500. These 
services fall 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.  
 
The file shows that you received specialist services on August 22, 2019. You have been asked to pay a $35 
copayment for these services. These services fall within the specialist services benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan.  
 
The total amount you have been asked to pay for these services is $1,940. 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 copayments for the services rendered from May 17, 2019 to August 22, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided to the enrollee on July 8, 2020. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not meet the required criteria for this testing. 
 
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 test at issue in this appeal appears to be a follow up and a screening. 
The enrollee did not have prior authorization for this testing. Medicare coverage criteria are not met.  
Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on July 8, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chest x-ray rendered on February 19, 
2019. 
 
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the coinsurance was applied 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 30% 
coinsurance for out-of-network basic imaging services (x-rays).  
 
Review of the file shows that you received a chest x-ray on February 19, 2019 from an out-of-network 
provider. You have been asked to pay a 30% coinsurance for these services. These services fall within the out-
of-network basic imaging services (x-rays) benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for the chest x-ray rendered on February 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on July 7, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because the 
right to recover for services provided to eligible beneficiaries is not extinguished by specific plan regulations. 
The Plan denied your request. The Plan says these services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the outpatient services are not supported in the record. Specifically, this claim was not billed with 
revenue code 0510. Based on this information, we decided that Medicare rules for coverage of the outpatient 
services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient services 
provided on July 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on August 20, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you shouldn't have 
to pay for something you did not need. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $174.49. The total amount you are being asked to pay is $34.90 ($174.49 x 20% = 
$34.90). The correct coinsurance has been applied to the equipment that was provided. Durable medical 
equipment falls within the durable medical equipment benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for durable medical equipment provided by a participating provider on August 20, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on June 22, 2020. 
 
You asked the Plan to pay for these services. You say that the enrollee did not have hospice services. The Plan 
denied your request. The Plan says the enrollee was on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 8, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the anesthesia services 
rendered on June 22, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the magnetic resonance angiography (70544) provided on September 
13, 2020. 
 
You asked the Plan to pay for the magnetic resonance angiography. You say that you would like 
reconsideration because this service denied as a duplicate in error. The Plan denied your request. The Plan says 
that CPT code 70544 is the column II code to CPT code 70553. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that MACs subject all line items for the same beneficiary, same NPI, and same date of service to 
NCCI edits. 
 
We find that CPT code 70544 is supported in the record. Specifically, CPT code 70544 was rendered by a 
different provider than who rendered 70553. It is not appropriate to apply NCCI edits to providers with 
separate NPIs. Based on this information, we decided that Medicare rules for coverage of the magnetic 
resonance angiography have been met. Therefore, we decided that the Plan has to pay for the magnetic 
resonance angiography (70544) provided on September 13, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical procedure provided on March 1, 2020. 
 
You asked the Plan to pay for the abscess incision and drainage (10061). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says the procedure code is not supported in the medical record. 
 
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 10061 is Incision and drainage of abscess (eg, carbuncle, 
suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or 
multiple . 
 
We find that CPT code 10061 is not supported in the medical record. Specifically, the medical notes state the 
procedure complexity as Simple. Based on this information, we decided that Medicare rules for coverage of the 
abscess incision and drainage (10061) have not been met. Therefore, we decided that the Plan does not have to 
pay for the surgical procedure provided on March 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye exam provided on 
November 18, 2019. 
 
You asked the Plan to waive the copayment for the medical eye exam. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received a medical eye exam provided on the date of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for Vision care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a medical eye 
exam on November 18, 2019. You have been asked to pay a $40 copayment for the medical eye exam. The 
medical eye exam falls within the Vision 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 the medical eye exam provided on November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation, cone beam CT 
capture and interpretation, and retreatment of previous root canal therapy provided on July 16, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, cone beam CT capture and 
interpretation, and retreatment of previous root canal therapy. You say that you would like the Plan to pay a 
portion of this claim because you are on a fixed budget. The Plan denied your request. The Plan says the 
procedures that are billed are in reference to endodontic services. The Plan also says that per the evidence of 
coverage there is not any coverage for these types of procedures. 
 
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 
problem focused limited oral evaluation, cone beam CT capture and interpretation, and retreatment of previous 
root canal therapy provided on July 16, 2020.