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

 
We decided that the Plan does not have to waive the copayment for podiatry services provided on May 20, 
2020. 
 
You asked the Plan to waive the copayment for podiatry services. You say that you should not owe a 
copayment for routine foot care. 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 $50 
copayment for podiatry services.  
 
You received podiatry services on May 20, 2020. The medical records show that you received services beyond 
routine foot care. Therefore, you are responsible to pay the $50 copayment.  
 
You have been asked to pay a $50 copayment for podiatry services. Podiatry services fall within the podiatry 
services 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 podiatry services provided 
on May 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant maintenance procedures provided on March 14, 
2019. 
 
You asked the Plan to pay for the implant maintenance procedures. 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 Plans 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 
implant maintenance procedures provided on March 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ECG provided on February 11, 2020. 
 
You asked the Plan to pay for the ECG. The Plan denied your request. The Plan says the 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 
ECG. 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 an ECG provided on February 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on February 4, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were instructed by your doctor to seek 
medical attention when experiencing symptoms you discussed. Upon the EMS arrival you were no longer in 
distress. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 4, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on May 27, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 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 medical services provided to the enrollee by an out-of-network provider 
on May 27, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the emergency care you received on 
January 9, 2019, and December 4, 2019. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible 
for the copayment. 
 
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 an $85 
copayment for each emergency room visit.  
 
Review of the file shows that you were provided emergency care on January 9, 2019, and December 4, 2019. 
You have been asked to pay an $85 copayment for each visit. The services fall within the emergency 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 copayments for the emergency care you 
received on January 9, 2019, and December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotic items provided on March 24, 2020. 
 
You asked the Plan to pay for orthotic items. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of payment for these items is correct, because the documentation 
submitted does not include an itemized shipping/billing invoice to indicate proof of deliver of the specific items 
billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient 
information to determine whether payment is due. The rules say that the information submitted by the provider 
must corroborate the medical documentation and confirm that coverage criteria have been met. 
 
We looked at the file and Medicare rules. The documentation submitted does not include valid proof of 
delivery of the specific items billed on this claim. The Plan requested this documentation, but it was not 
provided. Without this information, you have not furnished sufficient information to the Plan to justify payment 
of the claim as it has been billed. Based on this information, we decided that Medicare rules for coverage of 
orthotic items have not been met. Therefore, we decided that the Plan does not have to pay for orthotic items 
provided on March 24, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to waive the additional copayment applied to the application of a multi-layer 
compression system to the leg during an occupational therapy visit provided on February 27, 2020 billed with 
code 29581-GO. 
 
You asked the Plan to waive the additional copayment applied to the compression system application.. You say 
that it is felt that an additional copayment is not appropriate as this compression wrapping is a part of the 
occupational therapy plan of care and is billed as such. The Plan denied your request. The Plan says that a 
specialist service copayment was correctly applied to code 29581. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan says that enrollees must pay a 
$40 copayment for Medicare-covered occupational therapy visits. 
 
The Plan says the enrollee must pay an additional $45 copayment for specialist services provided on this date 
of service. However, based on the contract, the enrollee cannot be asked to pay more than a $40 copayment for 
a single occupational therapy visit. The code 29581 was billed with a GO modifier indicating it was performed 
as part of the occupational therapy plan of care. There is no language in the contract which would create a 
reasonable expectation that an additional copayment would be applied to a service provided during an 
occupational therapy visit. There is likewise no evidence to support applying a specialist copayment to this 
service as it appears this care would have been rendered by the same provider who performed the manual 
therapy. Therefore, we decided that the Plan has to waive the additional copayment applied to the application 
of a multi-layer compression system to the leg during an occupational therapy visit provided on February 27, 
2020 billed with code 29581-GO.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound provided on August 1, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for an ultrasound. 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. The Plan says 
that the member's primary care physician did not refer 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 an ultrasound provided on August 1, 2019 by an 
out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate needle biopsy (G0416) provided May 5, 2020. 
 
You asked the Plan to pay for prostate needle biopsy. You say that you are submitting for review as the service 
was medically necessary. The Plan denied your request. The Plan says CPT G0416 was not billed in 
accordance with Medicare national correct coding initiative policy - medically unlikely edits (MUE). 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code G0416 is 1. You billed 6 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of prostate needle biopsy specimens have not 
been met. Therefore, we decided that the Plan does not have to pay for the prostate needle biopsy (G0416) 
provided May 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on March 25, 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 not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on March 25, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided from November 5, 2019 
to November 21, 2019 by an out of network provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that the enrollee met medical necessity and 
the charges should be covered. The Plan denied your request. The Plan says no necessity for urgent or 
emergency situations 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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the servic 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 psychotherapy services provided from November 5, 2019 to November 21, 
2019 by an out of network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on March 26, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 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 medical services provided to the enrollee by an out-of-network provider 
on March 26, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on September 11, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physical therapy. 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. The 
Plan says that the member's primary care physician did not refer 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 physical therapy provided on September 11, 2019 
by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on August 6, 2019 
to September 24, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you have no information in the 
materials you have access to which states that the Plan will not reimburse for privately contracted providers. 
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. The Plan says that these services were self-referred. 
 
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 
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 outpatient mental health services provided on 
August 6, 2019 to September 24, 2019 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 breast prostheses services coded L8000, L8030, and 
L8035. 
 
You asked the Plan to pay for the breast prostheses. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the items rendered are not supported by the documentation. 
 
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 valid proof of delivery. Review of the file shows that the records submitted do 
not include an itemized shipping/billing invoice to indicate the specific supplies and proof of delivery. The 
provider submitted illegible faxed documentation in which none of the information could be determined. 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 the breast prostheses services coded L8000, 
L8030, and L8035.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 10, 2019. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic activities services coded 97530 provided on 
January 16, 2020. 
 
You asked the Plan to pay for the therapeutic activities 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 97530 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
We find that CPT code 97530 is not supported in the medical record. Specifically, the submitted documentation 
does not indicate the total time spent. Based on this information, we decided that Medicare rules for coverage 
of the therapeutic activities services have not been met. Therefore, we decided that the Plan does not have to 
pay for the therapeutic activities services coded 97530 provided on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns and a bridge 
 
You asked the Plan to pre-approve the dental services. You say that you need this crown and bridge. The Plan 
denied your request. The Plan says you are missing teeth in the posterior arch. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the requested services are not medically reasonable or necessary. Our physician reviewer found the 
provided x-ray reveals missing teeth #1,2,3,4,12,13,14,15,16 in the upper arch. There is severe periodontal 
disease noted on all remaining upper teeth with resultant bone loss in the 65% range.   In general, teeth with 
more than 50% missing bone are considered inadequate to act as abutment teeth for a fixed prosthesis. 
Therefore, as there are existing missing posterior teeth in the upper arch, under the Plan provisions there is no 
necessity for an upper fixed bridge.  In consideration of the periodontal condition, there also would not be 
medical necessity for the requested bridge as the bone support is inadequate for the appliance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve crowns and a bridge