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

 
We decided that the Plan does not have to pay for the laboratory services provided on September 19, 2019. 
 
You asked the Plan to pay for the laboratory services. 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided on September 19, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from June 27, 2019 to June 30, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that by denying inpatient services for their own failures, the Plan is trying to reduce reimbursement for the medically necessary care provided to the enrollee.The Plan denied your request. The Plan says that the medical records did not support that inpatient level of care was 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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the enrollee, with a history of CVA, hypertension, hyperlipidemia, pancreatic cancer, hypothyroidism, unsteady gait, and dementia was brought in by BLS ambulance to the emergency department for evaluation of syncopal episode followed by confusion and vomiting status post fall at home. Subsequently, the enrollee was diagnosed with syncope, urinary tract infection, anemia and was admitted as an inpatient to the Telemetry unit for further evaluation and management. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessaryhospital 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 been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from June 27, 2019 to June 30, 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 toopen the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forselective catheter placement (36225) provided on November 26, 2019.You asked the Plan to pay forthe selective catheter placement. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the service billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 36225 is  selective catheter placement, subclavian or innominate artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed.We asked our coder 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 selective catheter placement. Our reviewer says that CPT code 36225 does not meet criteria for billing or reimbursement consideration. Our reviewer found the procedure report does not include enough detailed documentation to verify this service was performed.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the selective catheter placement have not been met.Therefore, we decided that the Plan does not have to pay forselective catheter placement (36225) provided on November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper partial denture (D5213) provided on June 24, 2020. 
 
You asked the Plan to pay for the dental item. You say that the previous claim was submitted without your 
knowledge. You say that you were advised the provider would fix your partial denture for free and would not 
be billed to your insurance. You say that you need a new partial denture because it was so irreparably damaged. 
You also say that it broke the next day. The Plan denied your request. The Plan says the benefit for a partial 
denture has been exhausted. The Plan says that a denture repair cannot be billed within 6 months of the 
delivery of a new partial denture. 
 
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 benefit for a partial denture has 
been exhausted. The Evidence of Coverage clearly states that denture repair cannot be billed within 6 months 
of the delivery of a new partial denture. The record shows that you received a denture repair on February 19, 
2020. Therefore, we decided that the Plan does not have to pay for the upper partial denture (D5213) provided 
on June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visit you had with a specialist 
on June 4, 2020. 
 
You asked the Plan to waive the copayment for the telehealth specialist visit. You say that this visit was a 
phone call instead of an office visit because of COVID-19. You feel as though you shouldn't be penalized for 
doing a phone call instead of going into the office. The Plan denied your request. The Plan says you were 
charged this copayment correctly. The plan says that because the allowed amount for this service is less than 
your copayment obligation, you are responsible for the full amount ($29.27.) 
 
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 $45 
copayment for visits with a specialist.  
 
You have been asked to pay a $45 copayment for the telehealth specialist visit. The Evidence of Coverage 
clearly states that this copayment applies to telehealth visits as well. 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 telehealth visit you had with a specialist on June 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 64625) provided on June 8, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that L52863 provides a list of non-covered services.  
 
We looked at the file and Medicare rules. Per LCD L52863, CPT code 64625 is non-covered. 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 the services (CPT 64625) provided on June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided by a participating 
provider on January 2, 2020. 
 
You asked the Plan to waive the deductible for an office visit. You say that you do not agree with this being 
denied. The Plan denied your request. The Plan says these services were not denied. The plan says that the 
correct deductible amount has been applied. 
 
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 $198 deductible for physician/practitioner services/in-network.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
physician/practitioner services/in-network. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $198 deductible for physician/practitioner services/in-network. This cost sharing is a 
contractual obligation that had not been met at the time an office visit was received on January 2, 2020. The 
total amount you are being asked to pay is $96.85. Therefore, we decided that the Plan does not have to waive 
the deductible for an office visit provided by a participating provider on January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a lab examination of tissue (88305) 
performed on November 21, 2019. 
 
You asked the Plan to waive the copayment for a lab examination of tissue. You say that the provider should 
not have waited until 2020 to bill you and that you disagree with the cost for this date of service. The Plan 
denied your request. The Plan says the correct copayment was 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 
copayment for each visit for laboratory tests, non-radiological tests, diagnostic tests, flat film X-rays, and 
ultrasounds.  
 
You have been asked to pay a $20 copayment for a lab examination of tissue. A lab examination of tissue falls 
within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a lab examination of tissue (88305) performed on November 21, 
2019.  
 
Your complaint about the provider waiting until 2020 to bill you for this date of 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (77062) provided on 
May 27, 2020. 
 
You asked the Plan to pay for diagnostic digital breast tomosynthesis. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 77062 
has a status code of I which 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. 
 
We find that CPT code 77062 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 77062 has a status indicator of I. This means that CPT code 77062 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of diagnostic digital breast 
tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic 
digital breast tomosynthesis (77062) provided on May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive dental service (D1999) provided 
on July 7, 2020. 
 
You asked the Plan to pay for the dental service. You say that you went in for a filling. You say that the 
provider added a $15 charge for the personal protective equipment (PPE) needed due to Covid-19. You also 
say that you should be reimbursed for all thing related to Covid-19 and that the federal government would 
agree. The Plan denied your request. The Plan says that the unspecified preventive dental service is not listed as 
a covered service. The Plan also says that any service not listed is 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 service is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified preventive 
dental service (D1999) provided on July 7, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe actigraphy testing provided on April 20, 2020.You asked the Plan to pay forthe testing. The Plan denied your request. The Plan says this is not a covered service.The Plan must follow Medicare rules. Medicare rules say that actigraphy is a non-covered service when it is not done as part of a sleep test or when it is used for monitoring. We looked at the file and Medicare rules. The requested actigraphy testing is a non-covered services per LCD L36593. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plan does not have to pay forthe actigraphy testing provided on April 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen supplies (E0442) provided May 15, 2020 to May 29, 
2020. 
 
You asked the Plan to pay for the oxygen supplies. You say that the supplies were medically necessary. The 
Plan denied your request. The Plan says the maximum allowable units were exceeded. 
 
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 E0442 is 1. The provider billed 8 units, 54 units, 61 units, and 63 units of 
this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
oxygen supplies have not been met. Therefore, we decided that the Plan does not have to pay for oxygen 
supplies (E0442) provided May 15, 2020 to May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular services (92929, 93458) provided on 
March 19, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the cardiovascular services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or 
the provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the cardiovascular services (92929, 93458) 
provided on March 19, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) and wrist hand 
orthosis (L3916) provided. 
 
You asked the Plan to pay for the orthoses. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says these supplies cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
record indicates that the member did not receive these supplies and the proof of delivery ticket provided 
includes an invalid tracking number. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for 
shoulder elbow wrist hand orthosis (L3960) and wrist hand orthosis (L3916) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on July 9, 2020. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says 
prior authorization was not obtained as required under the plan benefits. 
 
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 
hospital outpatient clinic visit. 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 hospital outpatient clinic visit provided on July 9, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit and 
subsequent lab procedures (99214, 85025, 82044, 36415, 81003) provided on June 24, 2020, by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit and subsequent lab 
procedures. You say that you would like this claim reprocessed and approved for payment. The Plan denied 
your request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, 
payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
 
 
Therefore, we decided that the Plan does not have to pay for the established patient office or other outpatient 
visit and subsequent lab procedures (99214, 85025, 82044, 36415, 81003) provided on June 24, 2020, by an out 
of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating hospital on March 4, 2020, to March 18, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that your copayment is way too 
high. 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 $195 
copayment for outpatient surgery.  
 
You have been asked to pay $178.06 which is less than your copayment amount of $195 for each outpatient 
surgery. The total amount you are being asked to pay is $534.18 ($178.06 x 3 = $534.18). An outpatient 
surgery falls 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. 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 outpatient surgery provided by a participating provider on March 4, 2020, to March 18, 2020.
Appeal type: Transportation
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment and deductible for ambulance services. We decided that 
the Plan does not have to waive the copayment and deductible for ambulance services.  
 
You asked the Plan to waive the copayment and deductible for ambulance services. You say that you had no 
choice as to whether the provider was in-network or not. The Plan says that the claims were processed correctly 
and you are being charged the correct amount. 
 
We decided that the Plan has to waive the $300 deductible for ambulance services provided on May 26, 
2020.  
 
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 did not provide the EOC clearly showing that you owe a deductible for 
ambulance services. Therefore, we decided that the Plan has to waive the $300 deductible for ambulance 
services.  
 
We also decided that the Plan does not have to waive the $100 copayment for ambulance services 
provided on May 26, 2020. 
 
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 $100 
copayment for ambulance services. Therefore, we decided that the Plan does not have to waive the $100 
copayment for ambulance services.