Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services provided to the enrollee on July 16, 2018. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the correct claim was not filed timely. 
 
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. It appears that the plan?s contracted delegate did not provide verification of 
when the claims were submitted to substantiate the corrected claim as being untimely filed. Therefore, we 
decided that the Plan has to pay for the services provided to the enrollee on July 16, 2018.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation services (A0427 and A0425) provided on 
April 7, 2020. 
 
You asked the Plan to pay for the transportation services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this is a duplicate of a claim that has 
previously been processed and 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 transportation services have not been met. Specifically, the record shows that a claim for the 
same codes, enrollee and date of service has previously been processed and paid. The records do not indicate 
that this service was rendered more than once on the billed date of service. Therefore, we decided that the Plan 
does not have to pay for transportation services (A0427 and A0425) provided on April 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on May 19, 
2020. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you have never been charged 
in the past and disagree with the charges. 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 $5 
copayment for laboratory services.  
 
You have been asked to pay the allowed amount of $3.90, which is less than the $5 copayment for laboratory 
services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and supplies 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for laboratory services provided on 
May 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the wrist brace you received on February 
5, 2020. 
 
You asked the Plan to waive the coinsurance for the wrist brace. You say that you feel as though this is price 
gouging because you could have gotten a similar brace for much less money. The Plan denied your request. 
The Plan says the allowed amount for this brace is $180.53.  The plan says that you were charged the correct 
coinsurance for this item. 
 
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 durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the wrist brace. The wrist brace 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 the wrist brace you 
received on February 5, 2020.  
 
Please note that your complaint about the actual price (allowed amount) of the brace is a grievance that must be 
answered by your health plan.  Medicare does not permit us to make decisions regarding grievance issues.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement service (11042) rendered by the out of 
network (OON) provider on September 19, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service 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 this service. Therefore, we decided that the Plan does not 
have to pay for the debridement service (11042) rendered by the out of network (OON) provider on  
September 19, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on February 17, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation does not 
support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing 
was taken in an office setting, therefore the Place of Service (POS) code 81 ? indicating an independent lab 
setting ? is not appropriate for this claim. Based on this information, we decided that Medicare rules for 
coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory 
testing provided on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 11, 2019. 
 
You asked the Plan to pay for the services. You say that the claim was filed timely. The Plan denied your 
request. The Plan says the claim was filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until May 14, 2020. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the services provided on March 11, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (G0480) rendered by the out of network (OON) 
provider on August 19, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service 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 this service. Therefore, we decided that the Plan does not 
have to pay for the drug test (G0480) rendered by the out of network (OON) provider on August 19, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on February 17, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken 
in an office setting, therefore the Place of Service (POS) code 81 indicating an independent laboratory setting is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of 
lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing 
provided on February 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bedside commode. 
 
You asked the Plan to pre-approve the commode. You say that this is medically necessary. The Plan denied 
your request. The Plan says this request is 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 pre-approve the commode. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that you are physically incapable of using regular toilet 
facilities. The documentation does not indicate that you are confined to a single room/one level of the home 
and you are not confined living in a home without toilet facilities. 
 
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 commode have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a bedside commode.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased out of network on March 9, 2020.
You asked the Plan to pay for hearing aids purchased out of network. You say that these hearing aids should be
covered by the Plan. The Plan denied your request. The Plan says these hearing aids were not purchased from a
network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when purchased from an in network or Plan provider. You did not purchase these hearing
aids from a Plan provider. Therefore, we decided that the Plan does not have to pay for hearing aids purchased
out of network on March 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea core buildup, including any pins when required (D2950).You asked the Plan to pre-approvethis service. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy.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 service isnot among those covered under this benefit.Therefore, we decided th
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 9, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for the orthosis. You say that the claim should be paid because the enrollee needs it.
The Plan denied your request. The Plan says the provider did not acquire the required prior authorization for
the durable medical equipment.
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 January 9, 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 medical services provided on May 19, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the lumbar-sacral orthosis (L0648). You say that the claim should be paid. The Plan denied your request. The Plan says you did not obtain the prior authorization required.
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 19, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued oncology care to be provided by an out of network (OON) physician.
You asked the Plan to pre-approve the OON oncology care. You say that you have been treated by this provider and have received successful care and you feel you should be allowed to continue seeing this provider. The Plan denied your request. The Plan says you are not undergoing active treatment which requires continuation with the current provider. Your continued needs can be managed by a network provider.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 OON oncology care. Our reviewer says that the documentation does not support that continuation of care with the OON oncologist is medically reasonable and necessary. Our physician reviewer found this review relates to a request for continuing care from a now out of network oncologist for a 72 year old woman with metastatic breast cancer on oral chemotherapy. The plan has arranged for her to be seen by an in-network oncologist. The previous oncologist stated she was responding to treatment and included recommendation for such time as she has progression of the cancer. This information can be readily used by a new oncologist to continue breast cancer care safely. There is no medically reasonable and necessary rationale for her to continue with the same
oncologist. Breast cancer care has multiple standardized regimens including the one being used by the enrollee. Transfer of care to a network oncologist would be medically appropriate at this time. 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 OON oncology care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued oncology care to be provided by an out of network (OON) physician.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (99220) provided on November 8, 
2019. 
 
You asked the Plan to pay for the initial observation care. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says this service was included in CPT code 
99223. 
 
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, we have confirmed that code the 
initial observation care has a bundled relationship with code 99223 and cannot be paid as billed. This code 
cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for initial observation care (99220) provided on 
November 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two replacements of replaceable parts of semi-precision 
or precision attachments provided on April 22, 2020. 
 
You asked the Plan to pay for the replacements of replaceable parts of semi-precision or precision attachments. 
You say that you do not understand why this service is not covered. The Plan denied your request. The Plan 
says this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the 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 two 
replacements of replaceable parts of semi-precision or precision attachments provided on April 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to the enrollee on November 3, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says reimbursement for an assistant surgeon is never recommended with procedure code 
27596. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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. No medical documentation was provided to verify if the services 
by the assistant surgeon were medically necessary. Therefore, we decided that the Plan does not have to pay for 
the services provided to the enrollee on November 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office or other outpatient visit for the evaluation and 
management of an established patient, typically, 15 minutes are spent face-to-face with the patient and/or 
family (CPT Code 99213) provided on September 23, 2019. 
 
You asked the Plan to pay for the services. You say that the patient was seen by multiple providers from 
different specialties and previously billed charges shouldn't be bundled with the claim as this claim is 
separately payable. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
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. As the E/M code 99213 was billed 
within 10 days of the Global period for procedure code 17000 without an appropriate modifier; we find that 
Medicare rule for payment of this claim has not been met. If the provider determines that a billing error 
occurred during the initial submission of the denied claim, the plan would accept a submission of a corrected 
claim to consider services for payment. Therefore, we decided that the Plan does not have to pay for office or 
other outpatient visit for the evaluation and management of an established patient, typically, 15 minutes are 
spent face-to-face with the patient and/or family (CPT Code 99213) provided on September 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy (S9328) provided on November 
22, 2019. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because 
this is an infusion code, not durable medical equipment and this was not delivered to the member's home. The 
Plan denied your request. The Plan says S9328 has a status code of I which is not valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9328) 
provided on November 22, 2019.