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

We decided that the Plan does not have to pay for home infusion therapy (S9501) provided on December 7, 
2019, through December 13, 2019. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says procedure code S9501 has a status code if 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 S9501 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9501 has a status code of I. This means that CPT code S9501 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 home infusion therapy (S9501) provided on 
December 7, 2019, through December 13, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a stay at a SNF from March 6 to April 3, 
2020. 
 
You asked the Plan to waive the copayment for a stay at a SNF. You say that you could not be released from 
the SNF due to circumstances beyond your control. The Plan denied your request. The Plan says the correct 
copayment was 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 $178 
copayment for each day of days 21 to 100 for each Medicare-covered SNF stay.  
 
You have been asked to pay $1,424, or a $178 copayment for each day of 8 days, for a stay at a SNF. A stay at 
a SNF falls within the "Skilled nursing facility (SNF) 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 a stay at a SNF from March 6 to April 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and related medical services provided on July 
4, 2019 to October 25, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit and related medical services. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered 
benefit. 
 
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 office visit and related medical services 
provided on July 4, 2019 to October 25, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out of network 
(OON) provider from May 20, 2020 to June 17, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered by the out of network (OON) provider from May 20, 
2020 to June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy office visit (90833, 99214) provided on 
March 4, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy office visit. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy office visit (90833, 99214) 
provided on March 4, 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 oxygen concentrator provided on September 12, 2019 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the oxygen concentrator. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the item received by the enrollee is not a covered benefit 
when provided by an OON provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the oxygen concentrator provided on September 
12, 2019 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 services (S0028) provided on January 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee 
Schedule indicates that the code in question is not valid for Medicare purposes.  
 
We looked at the file and Medicare rules. Code S0028 is assigned a status indicator of ?I? under the Physician 
Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for 
reporting of, and payment for, these services. 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 
services (S0028) provided on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for closed treatment of shoulder dislocation, with manipulation 
(23650) provided May 21, 2019. 
 
You asked the Plan to pay for the shoulder dislocation treatment. You say that the enrollee received medical 
care from your providers. You are asking review of the enclosed supporting documentation and remit payment. 
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 23650 is closed treatment of shoulder dislocation, with 
manipulation; without anesthesia. 
 
We find that CPT code 23650 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of closed treatment of shoulder dislocation, with manipulation; without 
anesthesia. Based on this information, we decided that Medicare rules for coverage of the shoulder dislocation 
treatment have not been met. Therefore, we decided that the Plan does not have to pay for closed treatment of 
shoulder dislocation, with manipulation (23650) provided May 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for educational services related to the care of chronic kidney 
disease (G0420) provided on May 13, 2020. 
 
You asked the Plan to pay for educational services. You say that this should be covered. The Plan denied your 
request. The Plan says this was not billed with the appropriate diagnosis. 
 
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 G0420 is not supported in the medical record. Specifically, this code is to be used for 
services provided to patients with stage IV chronic kidney disease, but this claim was billed with a diagnosis of 
stage I chronic kidney disease. Based on this information, we decided that Medicare rules for coverage of 
educational services have not been met. Therefore, we decided that the Plan does not have to pay for 
educational services related to the care of chronic kidney disease (G0420) provided on May 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the prophylaxis, periodic oral evaluation, bitewing x-
rays, 3 periapical x-rays, a resin based composite, and palliative treatment provided from March 12, 2020, to 
May 28, 2020 by the out of network dentist. 
 
You asked the Plan to pay more for the dental services. You say that you would like these claims to be 
analyzed for additional coverage under medically necessary dental care. The Plan denied your request. The 
Plan says the provider in this case is not a network provider. The Plan says that the claims processed as out of 
network with a $0 copayment. The Plan also says that the provider can bill for the difference between what was 
billed and what was paid. 
 
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 and the services are listed as covered, 
they are subject to a higher cost share amount when you receive these services out of network. Out of network 
providers are able to bill you for the difference between what was billed and what was paid. Therefore, we 
decided that the Plan does not have to pay more for the prophylaxis, periodic oral evaluation, bitewing x-rays, 3 
periapical x-rays, a resin based composite, and palliative treatment provided from March 12, 2020, to May 28, 
2020 by the out of network dentist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for durable medical equipment provided by a 
participating provider on February 25, 2020, through May 31, 2020. 
 
You asked the Plan to waive the copayment for durable medical equipment. You say that you think this should 
be billed as one unit. 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 $10 
copayment for durable medical equipment/in-network.  
 
You have been asked to pay a $10 copayment for each month per durable medical equipment. The total amount 
you are being asked to pay is $110. Durable medical equipment falls within the durable medical equipment/in-
network 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 durable medical equipment 
provided by a participating provider on February 25, 2020, through May 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray provided on July 7, 2020. 
 
You asked the Plan to pay for the panoramic x-ray. You say that you were unknowingly charged for a 
panoramic x-ray. You say that the dentist knew you were responsible but didn't tell you the amount until the 
end. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
panoramic x-ray provided on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility visit (99309) provided on August 27, 
2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the nursing facility visit. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the nursing facility visit (99309) provided on 
August 27, 2019, by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and x-ray services provided on July 10, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit and x-ray services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services received were 
neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care. The Plan 
says there are equally qualified in-network providers available to you that could have provided the care and 
treatment you received. 
 
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 office visit and x-ray services provided on July 
10, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on February 7, 2020. 
 
You asked the Plan to pay for the drug testing. 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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not 
support that 22 or more drug classes were performed. Based on this information, we decided that Medicare 
rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the drug testing coded G0483 provided on February 7, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services you received on May 14, 2019. 
 
You asked the Plan to pay for the services. You say that this was part of your physical exam. The Plan denied 
your request. The Plan says that this is not covered for the listed diagnoses. 
 
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 services by a contract provider. The file does not show that the Plan provided notice 
that the services would not be covered. Under Medicare rules, this means the services is considered approved 
by the Plan. Therefore, we decided that the Plan has to pay for the lab services you received on May 14, 2019.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
April 9, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says there is no itemized billing/shipping invoice to verify the services billed 
 
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 proof of delivery to support medical necessity for the supplies provided in this 
case. There is no itemized billing/shipping invoice to verify the services billed. 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 a lumbar-sacral orthosis (L0650) provided to the enrollee on April 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paravertebral facet joint injection (64495) provided April 15, 
2020. 
 
You asked the Plan to pay for the injection. You say that you strongly disagree with this denial. Please review 
the medical records to reprocess this claim and pay accordingly. 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 64495 is injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral. 
 
We find that CPT code 64495 is not supported in the medical record. Specifically, the operative report did not 
include documentation of a diagnostic or therapeutic agent injection(s) into a lumbar or sacral paravertebral 
facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT). Based 
on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, 
we decided that the Plan does not have to pay for paravertebral facet joint injection (64495) provided April 15, 
2020.