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

We decided that the Plan does not have to pay for the surgical procedures (11056, 11721) provided on March 
19, 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 since the enrollee was enrolled in a federal 
hospice program, the services should be billed under Original Medicare. 
 
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) provided on March 
19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 30, 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 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on March 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient assisted living visit (99334) provided 
on August 17, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient assisted living visit. 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 established patient assisted living visit (99334) 
provided on August 17, 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 the rollator walker provided on April 24, 2020 by an out-of-
network provider. 
 
You asked the Plan to pay for the walker. You say that the walker is medically necessary and should be 
covered. The Plan denied your request. The Plan says the walker was not provided by a network supplier. 
 
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 item at issue in this appeal. The Plan did not pre-approve the item at issue. We 
found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does 
not have to pay for the rollator walker provided on April 24, 2020 by an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services received December 31, 2019 
through January 3, 2020. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the provider needs to bill 
Original Medicare. 
 
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 December 31, 2019. The services in question were provided 
before the end of that month. Responsibility for inpatient hospital services is not broken up. Rather, liability is 
determined based on who was responsible for services at the start of the hospitalization. Therefore, we decided 
that the Plan does not have to pay for the inpatient hospital services received December 31, 2019 through 
January 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chemotherapy administration services rendered by the 
out of network (OON) provider on January 16, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services were rendered by an out of 
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. 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 the chemotherapy administration services rendered by the out of network (OON) 
provider on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 21, 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 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on July 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus xT panel gene testing provided on February 27, 
2020. 
 
You asked the Plan to pay for the Tempus xT panel gene 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 has specific coverage criteria for this testing. Medicare has a 
specific code requirement for reporting this type of testing. Based on this information, we decided that 
Medicare rules for coverage of the Tempus xT panel gene testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the Tempus xT panel gene testing provided on February 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup (D2950). 
 
You asked the Plan to pre-approve core buildup (D2950). 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 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 pre-approve core 
buildup (D2950).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you 
had on December 9, 2019. 
 
You asked the Plan to waive the copayment for the CT scan. You say that before you had this test, you called 
the Plan and they said it was covered. You say that you cannot afford this amount. 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 $225 
copayment for advanced imaging services (including CT scans).  
 
You have been asked to pay a $225 copayment for the CT scan. 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 computed tomography (CT) scan you had on December 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 3, 2020. 
 
You asked the Plan to pay for the services. You say that the denied charges should be reconsidered. The Plan 
denied your request. The Plan says the services were rendered in a non-participating facility. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 laboratory services provided to the enrollee on 
June 3, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies (95913) provided April 22, 2020. 
 
You asked the Plan to pay for the nerve conduction studies. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the records 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 95913 is nerve conduction studies, 13 or more studies. 
 
We find that CPT code 95913 is not supported in the medical record. Specifically, full nerve conduction data 
from the studies performed were not provided for review. The provided records do not confirm that 13 or more 
studies were performed. Based on this information, we decided that Medicare rules for coverage of the nerve 
conduction studies have not been met. Therefore, we decided that the Plan does not have to pay for nerve 
conduction studies (95913) provided April 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 18, 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 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on March 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient surgery you had at an ambulatory surgical center on June 4, 2020.You asked the Plan to waive the copayment forthe outpatient surgery. You say that you assumed all copayments would be waived due to COVID-19 changes.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 $225 copayment for services at an ambulatory surgical center. You have been asked to pay a $225 copayment for the outpatient surgery. Records show that the copayment waiver that your Plan issued only applies to primary care, outpatient behavioral health services, and telehealth services.  Copaymentsfor ambulatory surgical services still apply. 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 forthe outpatient surgery you had at an ambulatory surgical center on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the sales tax for purchases on May 16, 2020 and 
May 29, 2020. 
 
You asked the Plan to reimburse you for the sales taxes. You say that the equipment was needed for recovery 
after surgery. The Plan denied your request. The Plan says they will reimburse you for the durable medical 
equipment but sales tax is not separately reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules say that sales tax is included in the calculation of 
reasonable charges. 
 
We looked at the file and Medicare rules. Durable medical equipment purchased privately through online 
agents are not eligible for coverage by your Medicare governed health plan. Sales tax is not reimbursable. 
Therefore, we decided that the Plan does not have to reimburse you for the sales tax for purchases on May 16, 
2020 and May 29, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay forthe skilled nursing facility (SNF) stay from March 1, 2020 to March 6, 2020.You asked the Plan to pay forthe SNF stay. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says that the claim processed with a $0.00 payment because that is the Medicare allowed payment based on guidelines for the service rendered.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 failed to substantiate their denial and explain why exactly there should be a $0.00 payment for the services rendered.Therefore, we decided that the Plan has to pay forthe skilled nursing facility (SNF) stay from March 1, 2020 to March 6, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for left and right shoulder arthrocentesis provided on May 26, 
2020. 
 
You asked the Plan to pay for the arthrocentesis. You say that the Plan should pay this claim. The Plan denied 
your request. The Plan says the ultrasound images submitted are not for the claim date of service. 
 
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 20611 is Arthrocentesis, aspiration and/or injection, 
major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent 
recording and reporting. 
 
We find that CPT code 20611 is not supported in the medical record. Specifically, there are no valid 
permanently recorded images to support the billed charge. Based on this information, we decided that Medicare 
rules for coverage of the arthrocentesis have not been met. Therefore, we decided that the Plan does not have to 
pay for left and right shoulder arthrocentesis provided on May 26, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99232) provided on February 11, 
2020. 
 
You asked the Plan to pay for subsequent hospital care. You say that the services should not be billed as 
hospice. 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. 
During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to 
the terminal illness. 
 
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 (99232) provided on February 11, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified periodontal procedure (D4999) provided on 
July 16, 2020 and July 17, 2020. 
 
You asked the Plan to pay for the unspecified periodontal procedure (D4999). You say that if this was a 
coverage issue, you want a portion of the claim to pay. 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 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 
unspecified periodontal procedure (D4999) provided on July 16, 2020 and July 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided on 
December 18, 2019. 
 
You asked the Plan to pay for the CGP 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. 
 
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. Based on this information, we decided that Medicare 
rules for coverage of the CGP testing have not been met. Therefore, we decided that the Plan does not have to 
pay for Comprehensive Genomic Profile (CGP) testing provided on December 18, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advance care planning including the explanation and 
discussion of advance directives (99497), initial nursing facility care (99306) and subsequent nursing facility 
care (99310) provided on May 29, 2020 to June 8, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for advance care planning including the explanation and discussion of advance 
directives, initial and subsequent nursing facility care. You say that the services 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 advance care planning including the 
explanation and discussion of advance directives (99497), initial nursing facility care (99306) and subsequent 
nursing facility care (99310) provided on May 29, 2020 to June 8, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health aide servicesYou asked the Plan to pre-approvehome health aide services. You say that you are in need of help around your home.The Plan denied your request. The Plan says there is no documentation that you are confined to your home, have a skilled need, or documentation indicating the frequency of the home health aide services required, Medicare criteria are not met and medical necessity is not established.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Specifically, you do not need skilled services and therefore do not meet the criteria for a home health aide.Therefore, we decided that the Plan does not have to pre-approvehome health aide services