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

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered 
from February 4, 2020 to February 19, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you disagree with the member 
responsibility. The Plan denied your request. The Plan says the copayment was 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 $100 
copayment per day for days 1-5 for in-network inpatient hospital services.  
 
Review of the file shows that you received inpatient hospital services from February 4, 2020 to February 19, 
2020. You have been asked to pay a $100 copayment per day for days 1-5 for these services, for a total of 
$500. These services fall within the in-network inpatient hospital services benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the inpatient hospital services rendered from February 4, 2020 to 
February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special pump services rendered on February 10, 2020. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are 
statutorily excluded.  
 
The provider submitted a claim for procedure code 99190 (special pump services). This code has a status 
indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. 
Therefore, we decided that the Plan does not have to pay for the special pump services rendered on February 
10, 2020.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on February 15, 2020 through 
February 22, 2020. 
 
You asked the Plan to pay for the home health services. You say that you would like reconsideration because 
you were informed that no prior authorization was needed for these services. The Plan denied your request. The 
Plan says home health services must be billed on a UB-04 form. 
 
The Plan must follow Medicare rules. Medicare rules say that institutional providers, including home health 
agencies, use one of two institutional claim formats to bill Original Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. The record shows that these services have been billed 
on a professional claim form. Home health services must be billed on a standard 837I claim form or UB-04. 
Therefore, we decided that the Plan does not have to pay for home health services provided on February 15, 
2020 through February 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
February 28, 2020 to March 4, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you feel that you should 
only owe a copayment for 4 days or less. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 
copayment for days 1-6 for inpatient hospital care.  
 
The record shows that you had an inpatient hospital stay from February 28, 2020 to March 4, 2020. Therefore, 
you are responsible to pay a $290 copayment for days 1-5 (February 28, 2020 to March 3, 2020). $290 
(copayment) x 5 (inpatient days) = $1,450. 
 
You have been asked to pay the total copayment amount of $1,450 for an inpatient hospital stay. An inpatient 
hospital stay falls within the inpatient hospital care 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 inpatient hospital stay provided from February 28, 2020 to March 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collagen dressing (A6021), gauze (A6402), absorptive 
dressing (A6253) and tape (A4452) provided on August 15, 2019. 
 
You asked the Plan to pay for the supplies. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation submitted did not include an 
itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery. 
 
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. The proof of 
delivery included in the submitted documentation is not for this enrollee. 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 collagen dressing (A6021), gauze (A6402), absorptive dressing (A6253) and tape 
(A4452) provided on August 15, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on May 15, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physicians intent that the tests be performed. 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 
drug testing services provided on May 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty to allow access for 
restorative procedure (D4212) provided on March 5, 2020. 
 
You asked the Plan to pay for the gingivectomy or gingivoplasty. You say that teeth #'s 29 & 30 have recurrent 
decay. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
gingivectomy or gingivoplasty to allow access for restorative procedure (D4212) provided on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for amputation services (CPT 27880) provided to the enrollee on 
October 31, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 27880-78 (1 unit) remains not supported. 
 
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 27880 is "amputation, leg, through tibia and fibula." 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the medical 
records provided do not provide sufficient information to validate that procedure 27880 78 was performed on 
October 31, 2019. Therefore, this service cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for amputation services (CPT 27880) provided to the enrollee on October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis, 
intraoral x-ray and crown provided on April 27, 2020 and May 18, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis, intraoral x-ray and 
crown. You say that that you weren't informed your dentist wasn't in-network. You say that you cannot afford 
to pay this. The Plan denied your request. The Plan says out-of-network dental services are not covered 
benefits. 
 
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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation, bitewing x-rays, prophylaxis, intraoral x-ray and crown provided on April 27, 2020 
and May 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care discharge day management (CPT Code 
99217) and initial observation care, per day (CPT Code 99220) provided to the enrollee from December 14, 
2019 through December 15, 2019. 
 
You asked the Plan to pay for the services. You say that you are requesting payment for initial observation care 
that was provided to the enrollee as medical necessity. The Plan denied your request. The Plan says a physician 
may report only one per diem E&M service from a range of per diem codes on a single date of service. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Review of the file shows that initial 
hospital care, per day (CPT Code 99223) and hospital discharge day management (CPT Code 99238), were 
previously billed/processed for these respective dates of service by the exact same provider. Therefore, we 
decided that the Plan does not have to pay for observation care discharge day management (CPT Code 99217) 
and initial observation care, per day (CPT Code 99220) provided to the enrollee from December 14, 2019 
through December 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis provided to the enrollee on December 17, 
2019. 
 
You asked the Plan to pay for the orthosis. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation submitted did not include a valid physician order for the billed item. 
 
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 HCPCS code L1851 is "Knee orthosis (ko), single upright, 
thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and 
rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf." 
 
We find that HCPCS code L1851 is not supported in the medical record. Specifically, there was no evidence in 
the case file of a physician order. Based on this information, we decided that Medicare rules for coverage of the 
orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis 
provided to the enrollee on December 17, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not indicate that skilled services are being received at home. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the records do not 
show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to 
improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's 
condition and/or prevent deterioration. The records do not show that skilled therapy is needed to effectively 
provide treatment, care, and/or services in order to improve the enrollee's level of function, or to 
establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent 
deterioration. As the enrollee does not require skilled therapy or skilled nursing services the enrollee does not 
meet the definition of home health aide services per Section 50.2 and the request for home health aide services 
are not reasonable and necessary to the treatment of the enrollee's illness or injury by the skilled professional 
staff. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture (D5214) provided on 
February 21, 2020. 
 
You asked the Plan to pay for the mandibular partial denture. You say that your tooth broke at the gum line, 
making your existing partial denture useless. You also say that you had to have the remainder of the tooth 
extracted, and a new partial made. The Plan denied your request. The Plan says this service is not a covered 
benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
mandibular partial denture (D5214) provided on February 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 11, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
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 
laboratory 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 laboratory services provided on December 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve the Prolia. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy 
exception criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 the Prolia. Our reviewer says that the 
Plan requires a trial of oral or IV bisphosphonate  before they will approve the requested drug. Our physician 
reviewer found the member has not tried and failed one of the required drugs. There is no documentation 
provided indicating that the Plan?s required drug would likely be less effective and/or likely have adverse 
effects for the enrollee. 
 
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 Prolia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia (J0897).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hand x-rays (73130) provided on February 20, 2020. 
 
You asked the Plan to pay for the hand x-rays. You say that you would like reconsideration because the 
member had multiple exams on the billed date of service. The Plan denied your request. The Plan says the 
submitted documentation supports 1 unit each of 73130-26-RT and 73130-26-LT, which were previously 
approved/paid. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the hand x-rays have not been met. Specifically, the record supports that one x-ray on the left hand 
and one x-ray on the right hand was rendered on the billed date of service. There is insufficient information to 
indicate that additional x-rays were performed. Therefore, we decided that the Plan does not have to pay for 
hand x-rays (73130) provided on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Gene Panel. 
 
You asked the Plan to pay for the testing. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says this testing was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pay for the testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there are provider records have been submitted for review. Panel testing, inclusive of testing 
that is not related to lung cancer or for which there are no associated therapies, was not medically necessary or 
reasonable. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Gene Panel.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (CPT Code 99308) provided 
to the enrollee on March 11, 2020. 
 
You asked the Plan to pay for the services. You say that you depend upon the hospital staff to verify eligibility 
and to obtain proper authorization from the enrollee's insurance company. The Plan denied your request. The 
Plan says the enrollee self-directed for services through their non-participating nursing facility. The Plan states 
the enrollee's primary care physician did not refer for 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 subsequent nursing facility care (CPT Code 
99308) provided to the enrollee on March 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment billed with the miscellaneous 
code E1399 on November 14, 2019. 
 
You asked the Plan to pay for durable medical equipment. You say that this should be covered. The Plan 
denied your request. The Plan says there is not a written order for this item. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that the supplier for all 
Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) must have an order from the 
treating physician before giving any DMEPOS item to an enrollee. The supplier must keep the order and proof 
of delivery documentation on file. 
 
We find that CPT code E1399 is not supported in the medical record. Specifically, this code is not included on 
the submitted physicians order. The record does not clearly document what this miscellaneous code is being 
used for. Based on this information, we decided that Medicare rules for coverage of durable medical equipment 
have not been met. Therefore, we decided that the Plan does not have to pay for durable medical equipment 
billed with the miscellaneous code E1399 on November 14, 2019.