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

 
We decided that the Plan does not have to pay for the subsequent nursing facility visit (99308) provided. 
 
You asked the Plan to pay for the subsequent nursing facility visit. 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, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date 
of discharge or revocation. 
 
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 subsequent nursing facility visit (99308) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 27, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
services at issue. 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 physician's services provided on July 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services, emergency department visit and 
office visit provided on September 16, 2019, through March 3, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because 
these services should be covered by the Plan. The Plan denied your request. The Plan says these bills should be 
submitted to the automobile insurance company. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested 
that the bill be sent to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the 
outpatient services until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for physical therapy services, emergency department visit and office visit 
provided on September 16, 2019, through March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) provided on June 16, 
2020. 
 
You asked the Plan to pay for the dental service. You say that it is unfair that that the enrollee has to pay most 
of this bill out of pocket. You say that your plan should have paid at least 50% of the bill. The Plan denied your 
request. The Plan says the dental record shows you had tooth # 4 extracted on the same date of service. The 
Plan says that guided tissue regeneration is not covered when performed in conjunction with an extraction. 
 
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 and guided tissue regeneration is listed 
as a covered service, there are limitations on this service. The Evidence of Coverage clearly states that guided 
tissue regeneration is not covered when performed in conjunction with an extraction. Therefore, we decided 
that the Plan does not have to pay for the guided tissue regeneration (D4266) provided on June 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on February 11, 2020 
and billed under codes 80307, 80157, 80177, 80201, 80162, 80159, and 80173. 
 
You asked the Plan to pay for lab services provided to the enrollee. You say that this claim should be paid. The 
Plan denied your request. The Plan says the documentation submitted did not support that the denied codes 
were performed with blood sampling.  Blood specimen collection is by venipuncture; however, the lab 
requisition does not state the specimen collected for the billed code; therefore, the billed service cannot be 
verified. In addition, the documentation submitted did not include lab results for this test. It is noted multiple 
attempts were made to obtain additional information from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim cannot be fully paid due to a 
discrepancy in the records and the type of specimen reported. Medicare billing criteria were not met.  
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on February 
11, 2020 and billed under codes 80157, 80177, 80201, 80162, 80159, and 80173.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-covered ambulance mileage, per mile (e.g. for miles 
traveled beyond closest appropriate facility) (A0888) provided July 15, 2020. 
 
You asked the Plan to pay for the non-covered ambulance mileage. You say that you feel this should be 
approved because this was an emergency and you were transported to this facility because this is where your 
providers are located. The Plan denied your request. The Plan says only mileage to the nearest appropriate 
facility equipped to provide treatment is covered. There is no coverage for miles traveled beyond the closest 
facility. 
 
The Plan must follow Medicare rules. Medicare rules says that ambulance transport is covered to the nearest 
appropriate facility. The records show that the requested hospital is 22.4 miles from your home. The nearest 
hospital was 5.2 miles from your home. There is no coverage for miles traveled beyond the closest facility. 
Based on this information, we decided that Medicare rules for coverage of the non-covered ambulance mileage 
have not been met. Therefore, we decided that the Plan does not have to pay for non-covered ambulance 
mileage, per mile (e.g. for miles traveled beyond closest appropriate facility) (A0888) provided July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite provided on November 5, 2019. 
 
You asked the Plan to pay for the resin-based composite. You say that according to your plan the charges for 
the restoration should be paid. The Plan denied your request. The Plan says this procedure is not covered under 
your plan. 
 
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 resin-
based composite provided on November 5, 2019.  
 
Your complaint about being misinformed about this service is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal analysis (D9950) provided on August 11, 2020. 
 
You asked the Plan to pay for the occlusal analysis (D9950). You say that you are requesting the service 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
occlusal analysis (D9950) provided on August 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four additional intraoral periapical x-rays and five 
extractions provided on June 23, 2020, and August 14, 2020. 
 
You asked the Plan to pay for the additional intraoral periapical x-rays and extractions. You say that your basic 
dental is supposed to cover 2 exams, cleaning, and x-rays each year. You also say that the provider told you the 
services would be covered. The Plan denied your request. The Plan says you have exhausted your annual dental 
benefit limit of 1 x-ray for the 2020 plan year. The Plan also says that you have exhausted the annual dental 
benefit limit of $500 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, dental x-rays are limited to one visit 
per year. The record shows that you received a first intraoral periapical x-ray on June 23, 2020, and your dental 
x-rays benefit has been exhausted. The Plan also offers a $500 annual dental benefit maximum. The record 
shows that you met the annual maximum benefit while processing the claim from the August 14, 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 four additional intraoral periapical x-rays and five extractions provided on June 23, 2020, 
and August 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on May 21, 2020 and 
billed under code G0483. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the records provided do 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 codes and provide medical records to support the services billed. In this case the medical records 
and physician documentation submitted is incomplete. Medicare billing criteria are not met. Therefore, we 
decided that the Plan does not have to pay for lab services provided to the enrollee on May 21, 2020 and billed 
under code G0483.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgical services performed on June 19, 
2020. 
 
You asked the Plan to waive the copayment for the surgical services. You say that you are appealing your cost-
share responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received cataract surgery services performed on July 19, 2020. You are asked 
to pay a $200 copayment for the services. Your EOC states that enrollees must pay a $200 copayment for each 
visit to an ambulatory surgical center. 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 surgical services 
performed on June 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgical services performed on July 10, 
2020. 
 
You asked the Plan to waive the copayment for surgical services. You say that you are appealing your cost-
share responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received cataract surgery services performed on July 10, 2020. You are asked 
to pay a $200 copayment for the services. Your EOC states that enrollees must pay a $200 copayment for each 
visit to an ambulatory surgical center. 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 surgical services 
performed on July 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on March 29, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you cannot afford this kind of 
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 $250 
copayment for ambulance services.  
 
You have been asked to pay a $250 copayment for an ambulance trip. An ambulance trip falls within the 
ambulance services 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 ambulance trip 
provided by a participating provider on March 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
May 20, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
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 subsequent nursing facility care (99309) 
provided on May 20, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual physical provided out of network on October 22, 2019. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says you had an annual routine physical exam with provider Caremount Medical 
PC on October 22, 2019. The claim was billed with procedure codes 99396 (Periodic comprehensive 
preventive medicine reevaluation and management of an individual including an age and gender appropriate 
history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of 
laboratory/diagnostic procedures, established patient; 40-64 years). The Plan says that you also had an annual 
routine physical exam with provider Caremount Medical PC on January 7, 2019. The claim was billed with 
same procedure code 99396. Per the Evidence of Coverage, the Plan will cover one annual routine physical 
exam each calendar year. You had this service done twice within a calendar year. Therefore, the plan is 
upholding the decision to deny payment for the annual routine physical exam you received on October 22, 
2019. 
 
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 only one annual 
physical exam is covered by the plan per year. You exhausted this benefit on January 7, 2019.  Therefore, we 
decided that the Plan does not have to pay for an annual physical provided out of network by Caremount 
Medical PC on October 22, 2019.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for air ambulance services provided to the enrollee on June 28, 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 that this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not provided any medical records to review for this case. The plan 
has not substantiated their denial of these services. Therefore, we decided that the Plan has to pay for air 
ambulance services provided to the enrollee on June 28, 2019.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on June 
29, 2020, June 30, 2020. 
 
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 this was billed with type of bill 130, which is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that the denied codes are not supported in the medical record. Specifically, a corrected claim must be 
submitted. Type of Bill 130 is incorrect to use in this case, as it is used when the provider is not anticipating 
payment. 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 inpatient hospital services provided to the 
enrollee on June 29, 2020, June 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgeon services provided to the enrollee on May 7, 
2020. 
 
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 Original Medicare does not allow all professionals to directly submit charges for the services that 
they provide. 
 
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. The provider is a RNFA. 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 assistant 
surgeon services provided to the enrollee on May 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on June 17, 2020. 
 
You asked the Plan to pay for the durable medical equipment. 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 when conducting a review of a covered DME 
item ordered by a physician, the Plan shall ensure that the physician saw the enrollee (including through the 
appropriate use of telehealth) and conducted a face-to-face assessment.  
 
We looked at the file and Medicare rules. The file does not contain documentation showing that the face-to-
face encounter included information supporting the enrollee was evaluated or treated for a condition that 
supports the DME ordered. The file does not document that the face-to-face encounter was made prior to the 
written order. Therefore, we decided that the Plan does not have to pay for the durable medical equipment 
provided on June 17, 2020.