Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a 
participating provider on May 22, 2020. 
 
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that this should be covered 
100%. The Plan denied your request. The Plan says the correct coinsurance has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for outpatient surgery/observation or surgery.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an outpatient surgery. The total 
allowed amount is $14,532.98. The total amount you are being asked to pay is $2,906.60 ($14,532.98 x 20% = 
$2,906.60). An outpatient surgery falls within the outpatient surgery/observation or surgery 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 an outpatient surgery provided by a participating provider 
on May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on April 27, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says he 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 
physician's 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 physician's services provided on April 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided May 22, 2020 to May 26, 
2020. 
 
You asked the Plan to pay for the outpatient services. You say that the records should support the necessity of 
the service in dispute. The Plan denied your request. The Plan says the number of units do not correspond with 
the date span. 
 
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 the outpatient services is not supported in the medical record. Specifically, per Medicare general 
rules of counting days guidelines, for all hospitals the plan counts the admission date and does not count the 
day of discharge or death. In this case, the provider billed admit date of service as May 22, 2020 and discharge 
status of 41, Still Patient or Expected to Return for Outpatient Services, date of Service of May 26, 2020, per 
claim image submitted, which equals 4 days of service, but provider billed 5 Days/Units of services under REV 
0120 Room Board-Semi. Based on this information, we decided that Medicare rules for coverage of the 
outpatient services have not been met. Therefore, we decided that the Plan does not have to pay for the 
outpatient services provided May 22, 2020 to May 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ALS ambulance services provided on March 16, 2020. 
 
You asked the Plan to pay for the ALS ambulance 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the 
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that the ALS entity does not have a contract with the volunteer ambulance company 
that provided the transport services. Therefore, we decided that the Plan does not have to pay for the ALS 
ambulance services provided on March 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health physical therapy visits. 
 
You asked the Plan to pre-approve additional visits. The Plan denied your request. The Plan says you are close 
to baseline, and skilled services are no longer required. 
 
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 6 additional visits. Our physician 
reviewer found that you are independent with wheelchair propulsion and bed mobility, and contact guard with 
ambulation using a rolling walker. You still display deficits in the left hip and knee strength compared to the 
right. The records do not show that skilled therapy services are required to effectively provide ongoing 
treatment in order to improve your level of function, or to perform a maintenance program to maintain your 
level of function or prevent deterioration. You have had extensive therapy for this condition, and the 
documentation does not indicate your functional level requires ongoing skilled therapy services. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional home health physical therapy visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery rendered. 
 
You asked the Plan to waive the copayment for these services. You say that the services were preventive and 
should have no copayment. 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 $200 
copayment for an ambulatory surgery visit.  
 
Review of the file shows that you received outpatient surgery in the form of an endoscopy. 
This is not a preventive service that Medicare or the Plan covers without a copayment. You have been asked to 
pay a $200 copayment for these services. These services fall within the ambulatory surgery visit 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 outpatient surgery rendered.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgical services rendered on March 31, 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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that claims must be 
billed with the most precise diagnosis code. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with diagnosis code R18.0 
and did not include the appropriate primary, first-listed, or principal diagnosis. 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 surgical services rendered on March 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on July 23, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that you should be allowed to get hearing aids from a 
specialist and not a company. The Plan denied your request. The Plan says the hearing aids were not purchased 
through the hearing aid vendor as required. 
 
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 the Plan's hearing aid vendor.  
 
We looked at the file and the Plan's rules. The Plan's EOC indicates that hearing aids are only covered when 
purchased from the Plan's hearing aid vendor. In this case, the hearing aids were not purchased from the Plan's 
hearing aid vendor as required. Based on this information, we decided that the Plan's rules for coverage of the 
hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids 
provided on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA) 
(87481, 87801, 87798) provided April 10, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that these CPT's (87798, 87481, 87801) are not 
experimental procedures. These procedures were performed and they are payable. Please reprocess this 
procedure correctly. The Plan denied your request. The Plan says there is insufficient clinic information 
available to substantiate the ordered testing. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
In this case, we find that the records do not support the billed services. Specifically, the records show that the 
plan made multiple attempts to obtain the needed records from the provider without success. We looked at the 
file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for infectious 
agent detection by nucleic acid (DNA or RNA) (87481, 87801, 87798) provided April 10, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for echocardiography (93306), a stress test 
(93015), myocardial perfusion imaging (78452), and surgical supplies (A9502) provided from March 10, 2020, 
to March 12, 2020. 
 
You asked the Plan to waive the cost-sharing for echocardiography, a stress test, myocardial perfusion imaging, 
and surgical supplies. You say that you did not expect these copayments. The Plan denied your request. The 
Plan says these services processed 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 $155 
copayment for radiological diagnostic services, a $30 copayment for non-radiological diagnostic services, and a 
20% coinsurance for medical supplies. 
 
You have been asked to pay $155 for echocardiography, $30 for a stress test, $155 for myocardial perfusion 
imaging, and $44.44 for surgical supplies ($222.20 allowed amount x 20% = $44.44). 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 cost-sharing for echocardiography (93306), a 
stress test (93015), myocardial perfusion imaging (78452), and surgical supplies (A9502) provided from March 
10, 2020, to March 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot safely return home until she is 
strong enough. The Plan denied your request. The Plan says the enrollee does not require an intensive rehab 
therapy program, or the involvement of a rehab specialist physician. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our physician reviewer found 
that the enrollee was admitted to the acute hospital for weakness and a fall and was treated for myocardial 
infarction. Her medical problems are stable. The complexity of the enrollee's nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The medical record supports a need for physical and occupational therapy, but it does not 
support a need for an intensive rehabilitation therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sensors for a Freestyle Libre continuous glucose monitor 
(CGM) provided on July 17, 2020. 
 
You asked the Plan to pay for the CGM supplies. You say that the order shows that this is medically necessary 
and should be covered. The Plan denied your request. The Plan says the documentation does not support that 
the enrollee has diabetes. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes. 
Although the order form indicates a diagnosis of Type II diabetes with multiple tests and insulin injections, the 
records provided do not corroborate this. Based on this information, we decided that Medicare rules for 
coverage of the CGM supplies have not been met. Therefore, we decided that the Plan does not have to pay for 
sensors for a Freestyle Libre continuous glucose monitor (CGM) provided on July 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental grafting services (D7953, D4266) provided on 
July 20, 2020. 
 
You asked the Plan to pay for the dental grafting services. You say that you were not advised these services 
would not be covered. The Plan denied your request. The Plan says these services are not covered by the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental grafting services 
(D7953, D4266) provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99214 provided on June 22, 2020. 
 
You asked the Plan to pay for the office visit. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as 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. 
 
We find that CPT code 99214 is not supported in the medical record. Specifically, this code was billed with 
modifier GT. Modifier GT cannot be billed with this code. Based on this information, we decided that 
Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for the office visit coded 99214 provided on June 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) and the filling 
(D2392) provided on August 18, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that you were advised multiple times by a 
plan representative that you would only be responsible for a $35 copayment. You say that you had to pay $180 
for the services at your appointment. You also say that you should be reimbursed for the services as this is what 
you were told would happen. The Plan denied your request. The Plan says the dental services that you received 
are not listed as covered. 
 
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 dental services you received are not 
among those covered under this benefit. The Evidence of Coverage says only preventive dental services are 
covered. The services that you received are not preventive in nature. Therefore, we decided that the Plan does 
not have to reimburse you for the limited oral evaluation (D0140) and the filling (D2392) provided on August 
18, 2020.  
 
Your complaint about being misinformed by a plan representative 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 24, 2020, by a non-
participating provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by a non-participating provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on July 24, 2020, by 
a non-participating provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nasal/sinus endoscopy services coded 31259 provided on 
September 5, 2019. 
 
You asked the Plan to pay for the nasal/sinus endoscopy 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 31259 is nasal/sinus endoscopy, surgical with 
ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the 
sphenoid sinus. 
 
We find that CPT code 31259 is not supported in the medical record. Specifically, the operative report did not 
include documentation of a surgical nasal sinus endoscopy, with total (anterior and posterior) ethmoidectomy, 
including sphenoidotomy with removal of tissue from the sphenoid sinus; therefore, this code cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of the nasal/sinus endoscopy 
services have not been met. Therefore, we decided that the Plan does not have to pay for the nasal/sinus 
endoscopy services coded 31259 provided on September 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on 
October 31, 2018, to November 7, 2018. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you were under the 
impression that this hospital stay would be billed as one stay, not two separate stays. The Plan denied your 
request. The Plan says the copayment applied correctly in this case. 
 
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 $320 
copayment per day for days 1-5, no charge for remainder of your covered hospital stay for inpatient hospital 
care.  
 
You have been asked to pay a total cost share of $1600 for the inpatient hospital care ($320 x 5). The service 
provided 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 the inpatient hospital care provided on October 31, 2018, to November 7, 2018.