Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network durable medical equipment provided on 
February 6, 2020. 
 
You asked the Plan to pay for out of network services. You say that the Plan should pay for this equipment. 
The Plan denied your request. The Plan says you did not have prior authorization for out of network 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 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 out of network durable medical equipment provided on February 
6, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the coinsurance for the radiation treatment and management 
services provided from March 17, 2020 to March 31, 2020. 
 
You asked the Plan to adjust the coinsurance for the radiation treatment and management services. You say that 
the Plan stated the provider was out-of-network and charged you the coinsurance incorrectly. The Plan denied 
your request. The Plan says you were charged this coinsurance correctly for the in-network provider. 
 
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 diagnostic tests and therapeutic services and supplies from an in-network provider.  
 
You have been asked to pay a 20% coinsurance for the radiation treatment and management services. The 
radiation treatment and management services falls 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 adjust the coinsurance for the 
radiation treatment and management services provided from March 17, 2020 to March 31, 2020.  
 
Your concerns with your out-of-network provider limit must be addressed with the Plan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory tests provided on March 11, 
2020. 
 
You asked the Plan to waive the copayment for laboratory tests. You say that you disagree with the charges 
because your doctor ordered the test. 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 $25 
copayment for lab services.  
 
You have been asked to pay the allowed amount of $20.06, which is less than the $25 copayment for laboratory 
tests. Laboratory tests 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 tests provided on March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, 
bitewings, and prophylaxis provided on March 9, 2020 by an OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation, first intraoral periapical x-ray, bitewings, and 
prophylaxis. You say that when you contacted the provider's office, you were told that they accepted your 
insurance plan. You also say that when you went for your visit, they took your card and told you everything 
would be covered. The Plan denied your request. The Plan says these services were rendered by a non-
contracted dental provider. The Plan also says that these services are not covered when performed by an OON 
provider. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation, first intraoral periapical x-ray, bitewings, and prophylaxis provided on March 9, 2020 by an 
OON provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a muscle-skin graft (15734) provided on December 20, 2019. 
 
You asked the Plan to pay for the muscle-skin graft. You say that you would like reconsideration because this 
service was medically necessary. The Plan denied your request. The Plan says that there is not enough 
information to determine how to member came to the provider or if the services were medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the muscle-skin graft. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the operative note confirms that the member underwent a standard reconstruction of a complex 
back wound. 
 
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 muscle-skin graft have been met. Therefore, we decided that the Plan has to 
pay for a muscle-skin graft (15734) provided on December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 11, 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 March 11, 2020 
by a non-participating provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nerve conduction test (95913) performed 
on April 13, 2020. 
 
You asked the Plan to waive the copayment for a nerve conduction test. You say that you were told you would 
only have a $5 copayment. 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 $150 
copayment for Medicare-covered diagnostic procedures and tests, excepting EKG and diagnostic colorectal 
screenings.  
 
You have been asked to pay a $150 copayment for a nerve conduction test. A nerve conduction test falls 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 a nerve conduction test (95913) performed on April 13, 2020.  
 
Your complaint about erroneous or misleading information about copayments received from the provider 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 discharge day management (99238) provided on September 
12, 2019. 
 
You asked the Plan to pay for discharge day management. You say that this should be covered. The Plan 
denied your request. The Plan says this code is 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 code 99238 is not supported in the medical record. Specifically, the submitted records show 
that the enrollee was discharged on September 11, 2019. The submitted documentation is insufficient to verify 
that discharge services were performed on the billed date of September 12, 2019. Based on this information, we 
decided that Medicare rules for coverage of discharge day management have not been met. Therefore, we 
decided that the Plan does not have to pay for discharge day management (99238) provided on September 12, 
2019.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for physical and occupational therapy provided from December 6, 2019 
through December 31, 2019. 
 
You asked the Plan to pay for physical and occupational therapy. You say that the therapeutic intervention met 
medical necessity guidelines. You say that the original appeal should be accepted and processed. The Plan 
denied your request. The Plan says that the services are not authorized because they are a part-A benefit for 
skilled nursing facility admissions and are included in the facility PPS payment. 
 
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. There is no supporting documentation that the services were provided during a 
Part A covered stay. Without evidence that payment was made for Part A services, the Plan's denial rationale is 
not substantiated. Therefore, we decided that the Plan has to pay for physical and occupational therapy 
provided from December 6, 2019 through December 31, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth specialist visit (99213) on June 
3, 2020. 
 
You asked the Plan to waive the copayment for a telehealth specialist visit. You say that the visit was not 
worthy of a copayment. 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 $40 
copayment for each specialist visit.  
 
You have been asked to pay a $40 copayment for a telehealth specialist visit. A telehealth specialist visit falls 
within the "Physician/Practitioner services, including doctor's office visits" 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 telehealth specialist visit (99213) on June 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 25, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 80307 (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the 
specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the 
records reflect of place of service of a doctor's office (POS 11). 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 drug testing services provided to the enrollee on March 25, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services provided from August 1, 2019 through August 2, 2019. 
 
You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied 
charges. The Plan denied your request. The Plan says that the records indicate that this was not an emergency 
and that there are contracted providers available for this service. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Furthermore, the facility you were seen at is in-network with the 
Plan. Therefore, we decided that the Plan has to pay for the services provided from August 1, 2019 through 
August 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 22, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for a wrist orthosis. You say that the services were necessary. The Plan denied your 
request. The Plan says while the services were necessary, Prominence Health Plan has in-network providers for 
these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on February 22, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $30 copayment charged for specialist services provided on 
May 29, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment was charged based on the services provided and the 
Plan contract agreement. 
 
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 $30 
copayment for specialist services.  
 
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 $30 copayment charged for specialist services provided on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the clinic services provided on February 15, 
2020. 
 
You asked the Plan to waive the deductible for the clinic services. You say that you should only have a $30 
copayment. The Plan denied your request. The Plan says you had not met any of your 2020 deductible at the 
time of claim processing. 
 
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 $290 deductible for medical services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category . The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is $290 deductible for medical 
services. This cost sharing is a contractual obligation that had not been met at the time the clinic services was 
received on February 15, 2020. Therefore, we decided that the Plan does not have to waive the deductible for 
the clinic services provided on February 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $250 copayment charged for ambulance transport 
provided on March 1, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe you owe this copayment. The 
Plan denied your request. The Plan says ambulance transport requires a cost share. 
 
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 $250 
copayment for ambulance transport. 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 $250 copayment charged for ambulance 
transport provided on March 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share charged for chiropractic services provided from 
March 27, 2020 to May 13, 2020. 
 
You asked the Plan to waive this cost share. You say that all this cost share should be waived because of Covid. 
The Plan denied your request. The Plan says cost share for this type of service is not waived due to Covid. The 
Plan states that some of the services provided were not related to manual manipulation of the spine and are not 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The Plan contract states there is a $20 copayment 
per visit for covered services. The records show that some of the services at issue were not manual 
manipulation of the spine. Therefore, we decided that the Plan does not have to waive the cost share charged 
for chiropractic services provided from March 27, 2020 to May 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 provided on September 9, 
2019. 
 
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 80307 is drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay 
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry 
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, 
MALDI, TOF) includes sample validation when performed, per date of service. 
 
We find that CPT code 80307 is not supported in the medical record. Specifically, the documentation submitted 
did not include a valid physician order/lab requisition form or medical records signed by the ordering 
physician. In addition, the place of service on the CMS-1500 form line 24B must reflect the location of the 
patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim 
history indicates that the specimen was obtained in an office setting place of service 11. 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 80307 provided on September 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure (D1999) provided on May 5, 2020. 
 
You asked the Plan to pay for the preventive procedure. You say that you are appealing personnel protective 
equipment. The Plan denied your request. The Plan says this service is not covered under your contract under 
any normal circumstances. 
 
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 
preventive procedure (D1999) provided on May 5, 2020.