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

 
We decided that the Plan has to hold you harmless for the glycosated hemoglobin test provided on April 10, 
2020. 
 
You asked the Plan to hold you harmless for the glycosated hemoglobin test. You say that you should not be 
billed for these services since there is supposed to be no charge for in-network lab services. The Plan denied 
your request. The Plan says that this service is not payable by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided with the glycosated hemoglobin test by a contract provider. This was billed with modifier -
GY which is not appropriate for this service as this test is not statutorily excluded by Medicare regulation. The 
file does not show that the Plan provided notice that the glycosated hemoglobin test would not be covered. 
Under Medicare rules, this means the glycosated hemoglobin test is considered approved by the Plan. 
Therefore, we decided that the Plan has to hold you harmless for the glycosated hemoglobin test provided on 
April 10, 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 to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for closed treatment of proximal humeral (surgical or anatomical 
neck) fracture (23600) provided January 26, 2020. 
 
You asked the Plan to pay for the closed fracture treatment. You say that please see the attached medical 
documentation that supports the billing of this claim. The Plan denied your request. The Plan says the records 
do 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 23600 is closed treatment of proximal humeral (surgical 
or anatomical neck)fracture; without manipulation.  
 
We find that CPT code 23600 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation or a procedure note of closed treatment of proximal humeral (surgical or 
anatomical neck) fracture; without manipulation. The plan had made multiple attempts to obtain the additional 
information from the provider without success. Based on this information, we decided that Medicare rules for 
coverage of the closed fracture treatment have not been met. Therefore, we decided that the Plan does not have 
to pay for closed treatment of proximal humeral (surgical or anatomical neck) fracture (23600) provided 
January 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit on August 7, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that this was a Wellness Visit with no 
copayment. 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 $10 
copayment for PCP office visit.  
 
You have been asked to pay a $10 copayment for the office visit. The office visit falls within the PCP office 
visit benefit category. The medical record shows this was an office visit for the evaluation and management of 
an established patient. 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 office visit on August 7, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic radiology mobile service provided in a SNF 
on June 8, 2020. 
 
You asked the Plan to pay for the diagnostic radiology mobile service. You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says that the transportation and set up costs are subject to 
consolidated billing. 
 
The Plan must follow Medicare rules. Medicare rules say that the technical component of radiology services in 
a SNF, during a covered stay, are not separately payable. 
 
Payment for this service would have been included under the facility claim. Payment to you for this service is 
the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for the 
diagnostic radiology mobile service provided in a SNF on June 8, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab services you received on July 29, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that the services are 
not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the lab services by a contract provider. The file does not show that the Plan provided notice 
that the lab services would not be covered. Under Medicare rules, this means the lab services is considered 
approved by the Plan. You were provided the lab services with a reasonable expectation that the services would 
be covered under your plan. Therefore, we decided that the Plan has to pay for the lab services you received on 
July 29, 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 to open 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 telehealth distant site services (G2025) provided on April 29, 
2020. 
 
You asked the Plan to pay for the telehealth distant site services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says per Medicare guidelines HCPCS 
code G2025 services furnished between January 27, 2020, and June 30, 2020 need to be billed with additional 
codes. 
 
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 G2025 is not supported in the record. Specifically, per Medicare guidelines, CPT code 
G2025 must be billed with additional codes and modifier 25. The submitted claim does not include the required 
 
 
codes. Based on this information, we decided that Medicare rules for coverage of the telehealth distant site 
services have not been met. Therefore, we decided that the Plan does not have to pay for telehealth distant site 
services (G2025) provided on April 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of anterior segment aqueous drainage device 
services provided on March 25, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the insertion of anterior segment aqueous drainage device services. You say that 
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
billed are not payable. 
 
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 insertion of anterior segment aqueous drainage 
device services provided on March 25, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete retroperitoneal ultrasound (76770) provided July 
10, 2020. 
 
You asked the Plan to pay for the ultrasound. You say that the services 76770 were denied as service frequency 
not met. Hence, you refilled the charges separately and it was denied again. So attached medical records to 
substantiate the services rendered. The Plan denied your request. The Plan says the records do not support the 
billed 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 76770 is ultrasound, retroperitoneal (eg, renal, aorta, 
nodes), real time with image documentation. 
 
We find that CPT code 76770-26-76 is not supported in the medical record. Specifically, the submitted 
documentation supports 1 (one) unit of 76770-26, which has been approved for payment. There is no additional 
documentation supporting an additional study which was billed. Based on this information, we decided that 
Medicare rules for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not 
have to pay for complete retroperitoneal ultrasound (76770) provided July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 25, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says this service was not urgent, emergent or approved in 
advance. 
 
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 medical services provided on March 25, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services you received on January 28, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that these services 
are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the lab services by a contract provider. The file does not show that the Plan provided notice 
that the lab services would not be covered. Under Medicare rules, this means the lab services is considered 
approved by the Plan. You received the lab services with the reasonable expectation that the services would be 
covered under your plan. Therefore, we decided that the Plan has to pay for the lab services you received on 
January 28, 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 to open 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 the medical services provided on August 24, 2020, by an 
OON provider. 
 
You asked the Plan to pay for an outpatient hospital clinic visit. You say that the enrollee's treatment was 
medically necessary. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 medical services provided on August 24, 2020, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services (99335) provided on July 8, 2020. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not emergent. There were network providers 
available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 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 physician services (99335) provided on July 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the technical component (TC) of the intraoperative 
neuromonitoring (IONM) testing provided during an inpatient surgery on May 29, 2020. 
 
You asked the Plan to pay for the TC of the IONM services. You say that these services should be paid as the 
IONM provider furnishes the supplies themselves. The Plan denied your request. The Plan says the TC of these 
services is not payable in the inpatient setting. 
 
The Plan must follow Medicare rules. Medicare rules say that inpatient PPS payment is payment in full to the 
hospital for inpatient operating costs. All items and non-physician services furnished to inpatients must be 
furnished directly by the hospital or billed through the hospital under arrangements.  
 
In this case, the TC of the services are not considered physician services. The value of the TC of these codes 
include values for practice expense and malpractice expense only, not for physician work. These services are 
provided directly by the hospital or paid by the hospital under arrangements. No separate Medicare payment 
can be made of the TC of these tests. Therefore, we decided that the Plan does not have to pay for the technical 
component (TC) of the intraoperative neuromonitoring (IONM) testing provided during an inpatient surgery on 
May 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic analysis of cochlear implant provided. 
 
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 hearing aids or examination for the purpose of prescribing, fitting, or changing hearing aids are 
excluded from coverage and not a covered benefit in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though the services may be appropriate in this case, neither Medicare nor the Plan covers or pays for these 
types of items and services. Therefore, we decided that the Plan does not have to pay for diagnostic analysis of 
cochlear implant provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 11, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the 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 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 medical services provided on May 11, 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 the podiatrist services provided on May 15, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for debridement (11721). You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says you did not request 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 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 podiatrist services provided on May 15, 2020 
by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you do not agree 
with this coinsurance. The Plan denied your request. The Plan says the correct coinsurance has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
allowed amount is $1,165.54. The total amount you are being asked to pay is $233.11 ($1,165.54 x 20% = 
$233.11). Durable medical equipment falls within the durable medical equipment benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for durable medical equipment provided by a participating.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies for maintenance of non-insulin drug infusion 
catheter, per week (A4221) and the infusion supplies for external drug infusion pump, per cassette or bag 
(A4222) provided to the enrollee. 
 
You asked the Plan to pay for these services. The Plan denied your request. The Plan says that he billed 
services were not supported. 
 
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. 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 the supplies for maintenance of non-insulin drug infusion catheter, per week (A4221) and the infusion 
supplies for external drug infusion pump, per cassette or bag (A4222) provided to the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing 
and/or skilled therapy services on a daily basis. The enrollee's physical function is at or near his baseline and he 
can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.