Persius/hicric huggingface dataset:
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 October 6, 2020. 
 
You asked the Plan to waive the deductible for an office visit. You say that this was an annual wellness exam. 
The Plan denied your request. The Plan says the correct deductible 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 $500 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 services that were provided went beyond an annual wellness 
exam; therefore, the correct deductible has been applied. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $500 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 October 
6, 2020. The total amount you are being asked to pay is $77.53. Therefore, we decided that the Plan does not 
have to waive the deductible for an office visit provided by a participating provider on October 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting services 
coded 76376 provided on July 30, 2020. 
 
You asked the Plan to pay for the 3D rendering with interpretation and reporting 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 supported by the documentation. 
 
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 76376 is 3D rendering with interpretation and reporting 
of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing under concurrent supervision; not requiring image postprocessing on an independent 
workstation. 
 
We find that CPT code 76376 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of 3D rendering with interpretation and reporting of computed 
tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing under concurrent supervision; not requiring image postprocessing on an independent 
workstation, therefore, the billed service cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of the 3D rendering with interpretation and reporting services have not been met. 
Therefore, we decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting 
services coded 76376 provided on July 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of residual tooth roots (cutting procedure) 
(D7250) and the panoramic radiographic image (D0330). 
 
You asked the Plan to pay for the dental services. You say that you should be reimbursed an additional amount 
for the extraction. The Plan denied your request. The Plan says the extraction is not a covered benefit, and the 
correct cost share applied to the radiographic image claim. 
 
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 removal of residual tooth roots 
(D7250) is not among those covered under this benefit.  You have been asked to pay a 50% coinsurance 
($23.50) for the panoramic radiographic image (D0330). $23.50 is 50% of the Plan's allowed amount of $47 
for this service. You have been asked to pay the correct amount for this service. Therefore, we decided that the 
Plan does not have to pay for the removal of residual tooth roots (cutting procedure) (D7250) or pay an 
additional amount for the panoramic radiographic image (D0330).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services rendered.

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 claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that outpatient hospital services must be reported under revenue code 0510 and TOB 13x. 

We looked at the file and Medicare rules. The file shows that the claim was not billed with the required revenue code and TOB. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient services rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
November 23, 2020. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you saw a physician 
assistant and not the doctor. You say you should not have to pay a copayment. The Plan denied your request. 
The Plan says you have been asked to pay the correct cost-sharing 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 $40 
copayment for visits to specialists.  
 
You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner services, including doctor's office visits benefit category. The record shows 
a physician's assistant is considered a practitioner. 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 specialist office visit provided on November 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CPAP machine provided from 
November 5, 2020, to December 5, 2020. 
 
You asked the Plan to waive the coinsurance for the CPAP machine. You say that you do not feel as though 
this machine is not worth $30 a month. The Plan denied your request. The Plan says you have been asked to 
pay the correct cost-sharing 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 20% 
coinsurance for covered items and related supplies.  
 
You have been asked to pay $30 which is 20% of the allowed amount for the CPAP machine on each date of 
service. The allowed amount is $150. ($150 x 20% = $30). The CPAP machine falls within Durable medical 
equipment (DME) and related 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 coinsurance 
for the CPAP machine provided from November 5, 2020, to December 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) 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 SNF extension is denied because the criteria was not met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found no required skilled nursing services are identified. The documentation supports that the enrollee would potentially benefit from skilled therapy services to improve her strength, but does not support that need for PT on a daily basis in an inpatient setting. It is not medically reasonable to provide skilled nursing or therapy services on daily basis in the skilled nursing facility setting.

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 continued admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out-of-network mental health care.

You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says you did not have prior authorization for out of network care.

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 contract specifically states outpatient mental health care can
require prior authorization and referral. The provider in this case is not a network provider with the Plan. The
Plan had network providers available who could have provided the services at issue in this appeal. 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 out-of-network mental health care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided November 16, 2020. 
 
You asked the Plan to pay for the limited oral evaluation. You say that your office visit should be covered as 
your annual dental cleaning. The Plan denied your request. The Plan says the service as provided and billed is 
not covered under your 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 
limited oral evaluation - problem focused (D0140) provided November 16, 2020.  
 
Your complaint about there potentially being a discrepancy in how services have been covered by the Plan 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Trazimera. 
 
You asked the Plan to pre-approve Trazimera. You say that the requested Trazimera is medically necessary. 
The Plan denied your request. The Plan says that the requested Trazimera is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Trazimera. Our reviewer says that the 
requested Trazimera is medically necessary. Our physician reviewer found although not the preferred regimen 
for HER2 breast cancer in a small subpopulation of elderly patients who cannot tolerate cytotoxic 
chemotherapy there is a role for single agent Trastuzumab. Limited data supports use for this indication and 
given this enrollee has MDS cytotoxic chemotherapy is not an option for her. The service is reasonable and 
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 Trazimera have been met. Therefore, we decided that the Plan has to pre-
approve Trazimera.  
 
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic imaging provided by a 
participating provider on January 15, 2020. 
 
You asked the Plan to waive the copayment for diagnostic imaging. You say that you do not agree with this. 
You say that you received this bill so late. 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 $75 
copayment for outpatient diagnostic tests/in-network/diagnostic tests.  
 
You have been asked to pay a $75 copayment for diagnostic imaging. Diagnostic imaging falls within the 
outpatient diagnostic tests/in-network/diagnostic tests 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 diagnostic imaging provided by a participating provider on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for crowns (D2740 x2), and core buildups (D2950 x2).

You asked the Plan to pay for crowns, and core buildups. You say that you were told by the provider that the services would be covered. The Plan denied your request. The Plan says these services are 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 crowns (D2740 x2), and core buildups (D2950 x2).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered.

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 procedure codes 80157, 80177, 80201, 80162, 80159, and 80173 are 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. 

We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 not supported in the medical record. Specifically, the records show that a urine specimen was collected and not blood testing. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 17, 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 laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the percutaneous access and closure of femoral artery 
(34713) provided on September 28, 2020. 
 
You asked the Plan to pay for the percutaneous access and closure of femoral artery. You say that you would 
like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT 34713 
was not billed in accordance with Medicare National Correct Coding Initiative Policy Medically Unlikely 
Edits. 
 
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 34713 is one. You billed two units of this code, exceeding the MUE. Based 
on this information, we decided that Medicare rules for coverage of the percutaneous access and closure of 
femoral artery have not been met. Therefore, we decided that the Plan does not have to pay for the 
percutaneous access and closure of femoral artery (34713) provided on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on October 29, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the office visit. 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 had network providers 
available who could have provided 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 office visit provided on October 29, 2020 by 
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided July 12, 2020. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Labs must register a test with the Diagnostics 
Exchange as it reflected on the order form and is run in the laboratory.  
 
We looked at the file and Medicare rules. The type of tests the provider has registered with the Diagnostic 
Exchange are not Medicare-covered. Furthermore, no prior authorization was requested for the services which 
were rendered by a non-contract provider. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
genetic testing (81479) provided July 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 27, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 27, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 27, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the requested semi-electric 
hospital bed is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for a semi-electric hospital bed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 a semi-electric hospital bed. Our 
reviewer says that the enrollee does not meet criteria for a semi-electric hospital bed. Our physician reviewer 
found based on the documentation provided, there is no evidence that the enrollee requires frequent and/or 
immediate repositioning while in bed.  Therefore, the requested semi-electric bed is not shown to be 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 a semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen and supplies (A0422) provided on September 7, 
2020. 
 
You asked the Plan to pay for the oxygen and supplies. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the requested supplies are not a Medicare 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that oxygen and other items and services provided as 
part of the transport are included in the FS base payment rate and are not separately payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen and supplies have not been met. Specifically, oxygen provided during ambulance 
transport is included in the base payment and not separately payable. Therefore, we decided that the Plan does 
not have to pay for the oxygen and supplies (A0422) provided on September 7, 2020.