Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the inpatient stay provided on June 1, 2020. 
 
You asked the Plan to waive the cost for the inpatient stay. You say that you had no knowledge of the 
additional $1,000 charge. You say that it is difficult to pay the charges. The Plan denied your request. The Plan 
says the cost share applied correctly. 
 
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 your deductible is $1,000. This is the amount you have to pay out-of-pocket 
before we will pay our share for your covered medical services. Until you have paid the deductible amount, 
you must pay the full cost of your covered services. Your contract with the Plan says that after you pay your 
$1,000 deductible, you pay $795 per stay.  
 
The item or service you asked the Plan to waive the cost for falls within the "Inpatient hospital care" benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1000 deductible 
applies to inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time 
the inpatient stay was received on June 1, 2020. Therefore, $1,000 has been applied to meet your deductible. 
  
 
 
Since the $1,000 deductible was met, you have also been asked to pay a $795 copayment for the inpatient stay. 
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 cost for the inpatient stay provided on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 30, 2019. 
 
You asked the Plan to pay for the services provided. You say that other bills from this physician have been 
paid. The Plan denied your request. The Plan says payment may not be provided for services performed by 
providers who have opted out of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
medical services provided on July 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0428, A0425) 
received on September 30, October 11, October 16, October 21, and November 4, 2019. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that these charges should be 
reconsidered. The Plan denied your request. The Plan says you were charged this cost sharing 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 $265 
copayment for ambulance services per date of service regardless of the number of trips. You had ambulance 
trips on 5 dates of service. The Plan charged you less than or equal to $265 for each of these dates of service. 
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 ambulance services (A0428, A0425) received on 
September 30, October 11, October 16, October 21, and November 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy services (HCPCS S9379) provided to 
the enrollee 
 
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 procedure is not valid for Medicare purposes. 
 
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 S9379 is "home infusion therapy, infusion therapy, not 
otherwise classified; administrative services, professional pharmacy services, care coordination, and all 
necessary supplies and equipment (drugs and nursing visits coded separately), per diem 
 
We find that CPT code S9379 is not supported in the medical record. Specifically, this code has a status 
indicator of "I" which means that it is not valid for Medicare purposes. 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 home infusion therapy services (HCPCS S9379) provided to the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on May 11, 2020. 
 
You asked the Plan to pay for the service. You say that this claim should be paid. The Plan denied your request. 
The Plan says Medicare does not provide payment to providers who have opted out of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program.  
 
The services at issue in this appeal were provided by a provider who has opted out of the Medicare program. 
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on 
May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on February 22, 
2020. 
 
You asked the Plan to pay for the outpatient hospital services. You say that this claim should be paid. The Plan 
denied your request. The Plan says the provider billed with CPT/HCPCS codes which are considered as 
unconditionally packaged services and are identified in the OPPS Addendum B with a SI = N for items and 
services packaged into APC rates. 
 
The Plan must follow Medicare rules. Medicare rules say that outpatient hospital services must be billed with 
HCPCS codes. 
 
In this case, an outpatient hospital claim was submitted with type of bill 0131. Neither of the two line items 
reported included an HCPCS code. As such, this claim cannot be paid as billed. Therefore, we decided that the 
Plan does not have to pay for the outpatient hospital services provided on February 22, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on June 2, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you could have received x-rays at the 
doctor's office instead of the emergency room. You say that if you were able to see someone at your doctor's 
office you could have avoided the $90 copayment. The Plan denied your request. The Plan says the copayment 
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 services in an emergency room. 
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" 
benefit category. The records show that you were treated in the ER. 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 ER visit provided on June 2, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department visit for the evaluation and 
management of a patient (99284) and ultrasound, retroperitoneal, real time with image documentation (76775) 
provided. 
 
You asked the Plan to pay for the emergency room services. You say that please review the medical records 
and process the claim accordingly. The Plan denied your request. The Plan says to process this claim we need 
an Explanation of Benefits from the primary insurance carrier. 
 
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 is the secondary 
insurer, the Plan cannot be held responsible for the emergency room services until the primary insurer has 
denied the claim for these services. Therefore, we decided that the Plan does not have to pay for emergency 
 
 
department visit for the evaluation and management of a patient (99284) and ultrasound, retroperitoneal, real 
time with image documentation (76775) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the referring facility is out-of-network. The 
Plan says that prior authorization was not obtained for these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for home health services provided 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for laboratory services provided. 
 
You asked the Plan to waive the deductible for laboratory services. You say that you were not informed that 
you would owe a deductible for laboratory tests. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 there is a $250 deductible for lab services. 
 
You received laboratory services. The record shows that you had paid $0 toward the $250 
deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $102.47.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $250 deductible for lab services. This cost sharing is a contractual 
obligation that had not been met at the time laboratory services was received. Therefore, we 
decided that the Plan does not have to waive the deductible for laboratory services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis, aspiration and/or injection (20605) trigger 
point injection (20553) and injection(s), single tendon sheath (20550) provided. 
 
You asked the Plan to pay for the injection services. You say that you have attached your Medicare Opt out 
approval letter. You have submitted claims for this enrollee in the past and received payment at the out of 
network rate, which makes it unclear why this is being denied. The Plan denied your request. The Plan says a 
provider must be enrolled in the Medicare program in order to receive payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
arthrocentesis, aspiration and/or injection (20605) trigger point injection (20553) and injection(s), single tendon 
sheath (20550) provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the post stabilization inpatient care provided from 6:30 PM 
on May 17, 2020 to May 20, 2020. 
 
You asked the Plan to pay for the post stabilization inpatient care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that the medical record supports that the enrollee was 
stable for transfer. 
 
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 post stabilization inpatient care. Our 
reviewer says that inpatient care was not medically reasonable and necessary for the enrollee in this case. 
Cardiology and Neurology each saw the patient on May 18, 2020, who each deemed the patient stable and clear 
for transfer. There were no dates where the patient was documented as not being stable enough for transfer. 
Our physician reviewer found that the patient was stable enough for transfer via ambulance on May 18, 2020 at 
6:30 PM. 
 
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 post stabilization inpatient care have not been met. Therefore, we decided 
that the Plan does not have to pay for the post stabilization inpatient care provided from 6:30 PM on May 17, 
2020 to May 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81201, 81235, 
81272, 81275, 81310, 81311, 81314, 81321) provided on June 9, 2020. 
 
You asked the Plan to pay for Guardant360 testing. You say that this is Medicare-covered testing. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. To report a CGP service, test providers should 
use CPT code 81479 at this time. 
 
We find that CPT codes 81120, 81121, 81173, 81201, 81235, 81272, 81275, 81310, 81311, 81314, and 81321 
are not supported in the medical record. Specifically, Guardant360 testing is considered a CGP test and should 
be billed with CPT 81479. Based on this information, we decided that Medicare rules for coverage of 
Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for 
Guardant360 testing (81120, 81121, 81173, 81201, 81235, 81272, 81275, 81310, 81311, 81314, 81321) 
provided on June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the aspiration and/or injection of large joint 
or joint capsule with Triamcinolone at a hospital outpatient clinic (20610, J3301, G0463) provided on June 10, 
2020. 
 
You asked the Plan to waive the copayment for the aspiration and/or injection of large joint or joint capsule. 
You say that the procedure you received should not be classified as a surgery. The Plan denied your request. 
The Plan says this service is considered an outpatient surgical procedure. Therefore, the copayment applied 
correctly in this case. 
 
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 $200 
copayment for Medicare-covered outpatient surgical service.  
 
You have been asked to pay a $200 copayment for the aspiration and/or injection of large joint or joint capsule. 
These services provided fall within the Medicare-covered outpatient surgical 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 the aspiration and/or injection of large joint or joint capsule 
with Triamcinolone at a hospital outpatient clinic (20610, J3301, G0463) provided on June 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services received by the enrollee on June 24, 
2020. 
 
You asked the Plan to pay for the services. You say that this was needed out of the service area. The Plan 
denied your request. The Plan says the claim was denied as out-of-network services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The rendering 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 pathology services received by the enrollee on 
June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the echocardiography provided on July 27, 
2020. 
 
You asked the Plan to waive the deductible for the echocardiography. You say that you normally have a $20 
copayment. You say that you weren't informed of the $250 deductible. The Plan denied your request. The Plan 
says the deductible applied correctly. 
 
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 your deductible is $250. This is the amount you have to pay out-of-pocket 
before we will pay our share for your covered medical services. Until you have paid the deductible amount, 
you must pay the full cost of your covered services.  
 
The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests 
and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that your $250 deductible applies to outpatient diagnostic tests. This cost sharing is a 
contractual obligation that had not been met at the time the echocardiography was received on July 27, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible for the echocardiography provided 
on July 27, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 
8, 2020 to June 11, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
appropriate home health date bill of type was not billed correctly. Therefore, we decided that the Plan does not 
have to pay for the home health services provided to the enrollee from June 8, 2020 to June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite provided on January 16, 2020. 
 
You asked the Plan to pay for the resin-based composite. You say that your tooth was already damaged, and 
you needed the crown to protect it. The Plan denied your request. The Plan says this service is not covered 
under any condition. 
 
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 January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 27, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says a revenue 
code was not reported for the services provided. 
 
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 G0466 is federally qualified health center (FQHC) visit, 
new patient; a medically-necessary, face-to-face encounter (one-on-one) between a new patient and a FQHC 
practitioner. 
 
We looked at the file and the rules. We find that the services provided was not billed with a valid revenue code. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the medical services provided on March 27, 2020.