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

We decided that the Plan does not have to waive the coinsurance for durable medical equipment and diagnostic 
testing and copayment for a specialist office visit provided by participating providers on March 4, 2020, to May 
18, 2020. 
 
You asked the Plan to waive the coinsurance and copayment for durable medical equipment, diagnostic testing 
and a specialist office visit. You say that you do not agree with this copayment or coinsurance. The Plan denied 
your request. The Plan says the correct cost sharing amounts have 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 and outpatient diagnostic tests/in-network/CT scan and a $45 
copayment for physician/practitioner services/in-network/specialist.  
 
You have been asked to pay less than a 20% coinsurance of the allowed amount for durable medical equipment 
and diagnostic testing. The total allowed amount is $1,637.37. The total coinsurance amount is $327.47 
($1,637.37 x 20% = $327.47). You have been asked to pay a lesser amount of $306.57. You have also been 
asked to pay a $45 copayment for a specialist office visit. The total amount you are being asked to pay is 
$351.57 ($306.57 x 20% = $351.57). Durable medical equipment falls within the durable medical equipment 
benefit category, diagnostic testing falls within the outpatient diagnostic tests/in-network/CT scan benefit 
category and a specialist office visit falls within the physician/practitioner services/in-network/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 coinsurance for durable medical equipment and diagnostic 
testing and copayment for a specialist office visit provided by participating providers on March 4, 2020, to May 
18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation hospital services and inpatient hospital 
services provided from February 7, 2020 to February 11, 2020. 
 
You asked the Plan to pay for the observation hospital services and inpatient hospital services. You say that 
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
rendered were not medically necessary. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.  
 
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 observation hospital services and 
inpatient hospital services. Our reviewer says that the documentation does not support that the services 
rendered were medically reasonable or necessary. Our physician reviewer found the enrollee presented to a 
nonPlan Emergency Department on February 7, 2020 complaining of bilateral leg pain and slurred speech 
lasting approximately 30 seconds. The enrollee was evaluated and admitted to the Naples Community Hospital 
for evaluation of leg pain and weakness at an observation level of care on February 7, 2020 and then converted 
to inpatient level of care on February 9, 2020, Extensive work up was unremarkable except for chronic 
compression fracture of L3-4 and diffuse LS disc disease without cord compression. The enrollee was 
discharged home on February 11, 2020. The documentation supports that the enrollee was hemodynamically 
and neurologically stable and appropriate for ambulance transport with monitoring to a Plan facility for 
observation/admission level of care services after the emergency room evaluation. There was no documentation 
provided requiring post-stabilization care services. 
 
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 observation hospital services and inpatient hospital services have not been 
met. Therefore, we decided that the Plan does not have to pay for the observation hospital services and 
inpatient hospital services provided from February 7, 2020 to February 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a nerve block procedure (64680-59) provided July 6, 2020. 
 
You asked the Plan to pay for the procedure. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the number of units billed exceeds the allowed amount. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 64680 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, 
we decided that the Plan does not have to pay for a nerve block procedure (64680-59) provided July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99203) and wound debridement 
services (11042) provided May 22, 2019. 
 
You asked the Plan to pay for the office visit. You say that resubmitting the claim with the initial denial EOB 
to show timely filing. You originally submitted the claim on 6/13/2019, within timely filing guidelines. The 
Plan denied your request. The Plan says the claim was not received within the allowed 12 month time frame. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the office visit was not filed until August 4, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the outpatient office visit (99203) and wound debridement services (11042) 
provided May 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the custom fabricated abutment and abutment supported 
crown for tooth #31 provided on March 11, 2020. 
 
You asked the Plan to pre-approve the custom fabricated abutment and abutment supported crown. You say 
that you had to have the implant so there would be an opposing surface opposite of the tooth that was holding 
the bridge in place. The Plan denied your request. The Plan says implant services are not covered for posterior 
teeth. 
 
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, implant services are only covered for 
anterior teeth. Tooth #31 is a posterior tooth. Therefore, we decided that the Plan does not have to pre-approve 
the custom fabricated abutment and abutment supported crown for tooth #31 provided on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on June 6, 2020 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. 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 podiatry services provided on June 6, 2020 by an 
out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgical procedure you had at 
an outpatient hospital facility on May 29, 2020. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you were not aware this 
would be billed as an outpatient hospital procedure.  You said it was just you and the doctor in the room during 
the procedure. 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 a $250 
copayment for surgery services in an outpatient hospital setting.  
 
You have been asked to pay a $250 copayment for the outpatient surgery. Records show that this service was 
performed and billed at an outpatient hospital facility. In addition, the website for the facility where you had 
this service clearly states that it is a hospital facility. 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 outpatient surgical procedure you had at an outpatient hospital facility on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on February 17, 2020. 
 
You asked the Plan to waive the coinsurance for an injection. You say that it isn't your fault that it took 5 
months for you to receive the bill. 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 Medicare Part B prescription drugs/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $1,612.44 ($1,612.44 x 20% = $322.49). The correct coinsurance has been applied to the injection 
that was provided. An injection falls within the Medicare Part B prescription drugs/in-network 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 an injection provided by a participating 
provider on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital visit, initial hospital care (99222) provided 
January 10, 2020. 
 
You asked the Plan to pay for initial hospital care. You say that this was for an inpatient consult that was not 
related to hospice. You request review of the documents in their entirety and process this claim for payment per 
contract guidelines. The Plan denied your request. The Plan says Original Medicare would be responsible for 
payment of all Medicare covered services related or unrelated to the member's terminal condition until the first 
day of the month following the month in which hospice was revoked or discharged. 
 
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 January 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 inpatient hospital 
visit, initial hospital care (99222) provided January 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical procedures (11056, 11721 99334) provided on 
January 10, 2020. 
 
You asked the Plan to pay for the surgical procedures. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the Medicare hospice benefit covers all 
hospice care from the effective date of election to the date of discharge. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the surgical procedures (11056, 11721 99334) provided on 
January 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99231) provided on December 1, 
2019. 
 
You asked the Plan to pay for hospital care. You say that the services rendered were unrelated to hospice care. 
The Plan denied your request. The Plan says the fee-for-service (FFS) benefit is the time where the member 
revokes hospice until the start of the new month. During this time Traditional or Original Medicare is still 
responsible for payment of medical services both unrelated and related to the hospice diagnosis. This benefit 
also covers any service unrelated to the hospice diagnosis during active hospice periods prior to the Medicare 
Advantage plan considering the claim for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent hospital care (99231) provided on December 1, 
2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on March 8, 2020 through 
March 11, 2020 while under hospital observation. 
 
You asked the Plan to pay for self-administered drugs. You say that you do not believe you should have to pay 
for something you did not know insurance didn't cover. The Plan denied your request. The Plan says self-
administered drugs are not covered under Part B. 
 
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 pay for self-administered drugs provided 
on March 8, 2020 through March 11, 2020 while under hospital observation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating 
provider on July 15, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you do not agree with this copayment. 
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 $150 
copayment for outpatient diagnostic tests/advanced imaging service.  
 
You have been asked to pay a $150 copayment for a CT scan. A CT scan falls within the outpatient diagnostic 
tests/advanced imaging service 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 
CT scan provided by a participating provider on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extracapsular cataract removal with insertion of 
intraocular lens prosthesis (66984) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve Removal of cataract with insertion of lens, simple. You say that the services 
are medically necessary. The Plan denied your request. The Plan says there are in-network facilities in your 
area that can perform this service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the extracapsular cataract removal with insertion of intraocular lens prosthesis (66984) to be provided by an out 
of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 genetic testing. 
 
You asked the Plan to pay for the Guardant360 genetic testing. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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, Medicare guidelines say when billing for the Guardant360 molecular lab panel, procedure code 
81479 is the only code available for billing. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the Guardant360 genetic testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endoscopy, surgical; operative tissue ablation and 
reconstruction of atria, limited (eg, modified MAZE procedure), without cardiopulmonary bypass (CPT Code 
33265) or MAZE procedure for the enrollee. 
 
You asked the Plan to pre-approve this surgery. You say that this surgery is medically necessary. The Plan 
denied your request. The Plan says Medical necessity has not been established. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 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 this surgery. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the thorascopic MAZE procedure is a surgical approach in an attempt 
to restore and maintain normal sinus rhythm in patients with atrial fibrillation.  If ablation is thought to be 
medically necessary, current guidelines do not recommend a surgical approach to ablation over conventional 
percutaneous ablation. Surgical approach to ablation is not an accepted standard of practice and has not been 
shown to be superior to percutaneous atrial fibrillation ablation in any large-scale trials and is associated with 
higher risk of complications.  MAZE procedures therefore are considered appropriate only when performed in 
conjunction with other heart surgery that already requires being on pump such as valve replacement or 
coronary artery bypass, neither of which this patient requires.  The enrollee has no palpitations with atrial 
fibrillation and needs to be maintained on anticoagulation anyway for his history of pulmonary embolism.  
Given this information and his advanced age a rate control strategy seems most appropriate.  Finally, there are 
presently NIH sponsored trials currently enrolling patients to assess whether or not a surgical approach to 
ablation may be preferred in certain patient populations compared to established catheter-based ablation 
procedures (reference 4).  Therefore, at this time, the stand-alone surgical MAZE procedure should be 
considered investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (eg, 
modified MAZE procedure), without cardiopulmonary bypass (CPT Code 33265) or MAZE procedure for the 
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (92012, 92071) provided January 15, 2020. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim is a duplicate. 
 
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 92012 & 92071 is not supported in the medical record. Specifically, the claim as billed 
is a duplicate of claim number 820200160053819. Insufficient documentation was provided to show this was a 
separate and distinct service. 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 an office visit 
(92012, 92071) provided January 15, 2020.