Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided June 5, 2019 to June 7, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically 
necessary. The Plan denied your request. The Plan says that the enrollee's needs could have been met in an 
outpatient setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier emergency and/or observation care) would 
span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided June 5, 2019 to June 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient office visit (99213) medical examination and 
evaluation, (92012) and visual field test (92081) provided on February 21, 2020 by an out of network (OON) 
provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that your PCP told you there was nothing 
more they could do and referred you to this provider and you were not aware that the provider was not 
participating and services would not be covered. The Plan denied your request. The Plan says enrollee's must 
receive services from an in-network provider. Non-emergent services with non-contracted providers require 
prior-authorization prior to services being rendered. 
 
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 outpatient office visit (99213) medical 
examination and evaluation,(92012) and visual field test (92081) provided on February 21, 2020 by an out of 
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on May 3, 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 procedure code 64718 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. In this case, the CPT Code Manual definition of code 64718 is neuroplasty and/or transposition; ulnar nerve at elbow. We find that CPT code 64718 is not supported in the medical record. Specifically, there is no documentation of neuroplasty and/or transposition of the ulnar nerve. 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 surgical services rendered on May 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
thorax (71250) provided on April 20, 2019. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $60 
copayment for complex diagnostic radiology services.  
 
You have been asked to pay a $60 copayment for the CT scan provided. 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 computed tomography (CT) scan of the thorax (71250) provided on April 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic, five prefabricated abutments, and five abutment 
supported retainers provided on February 6, 2020. 
 
You asked the Plan to pay for the pontic, prefabricated abutments, and abutment supported retainers. The Plan 
denied your request. The Plan says these services are not covered under the enrollee's plan. 
 
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 
pontic, five prefabricated abutments, and five abutment supported retainers provided on February 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the parenteral nutrition solution rendered on December 12, 2019 to December 18, 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 procedure codes B4185 and B4193 are not supported.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. The file shows that there is no valid proof of delivery for the dates of service at issue. 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 parenteral nutrition solution rendered on December 12, 2019 to December 18, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing rendered on August 9, 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 laboratory services must be ordered by a 
physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 
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 definitive drug testing rendered on August 9, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the office visits provided on May 6, 2019 
and June 3, 2019. 
 
You asked the Plan to waive the coinsurance for the office visits. You say that the Explanation of Benefits 
instructed you to not pay the bill. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing 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 40% 
coinsurance for each Medicare-covered podiatry visit.  
 
You have been asked to pay a total of $79.90 for the office visits. The office visits fall within the ?Podiatry 
services? benefit category. See chart below. 
  
 
Dates of Service Service Allowed Amount Coinsurance Member Liability 
May 6, 2020 Office visit $118.69 40% $47.48 
June 3, 2020 Office visit $81.05 40% $32.42 
Total    $79.90 
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the office visits provided on May 6, 2019 and June 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile testing provided on March 9, 
2020. 
 
You asked the Plan to pay for genetic testing. You say that the treating physician ordered this testing to 
determine if there was a more effective therapy to treat the enrollee. The Plan denied your request. The Plan 
says the denial of payment for this testing is correct, because this testing was not billed with the appropriate 
coding. 
 
The Plan must follow Medicare rules. Medicare rules say that comprehensive genetic profiling testing must be 
billed with procedure code 81479 for date of service March 9, 2020.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
comprehensive genomic profile testing provided on March 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 22853 x2) provided on February 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 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. In this case, the CPT Code Manual definition of code 22853 is "Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)". We asked our coding 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 services. Our reviewer says that the use of CPT code 22853 is not supported by the records provided. Our coding reviewer found CPT 22853 x2 does not meet criteria as the operative report documents fusion at one level was performed. We looked at this coder's review, the file, and Medicare rules. 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 (CPT 22853 x2) provided on February 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided from March 12, 2020 through 
March 26, 2020. 
 
You asked the Plan to pay for physical therapy. You say that the medical records and referral should be 
reviewed to adjust payment for the claim. The Plan denied your request. The Plan says authorization is required 
for outpatient rehabilitation after the initial 12 visits. 
 
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 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 from March 12, 2020 through March 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 3, 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. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive eye examination (92004) outpatient office visit for the evaluation and management (99204) and scanning computerized ophthalmic diagnostic imaging (92134) provided on September 11, 2019 by out of network (OON) providers.
You asked the Plan to pay for the vision services. You say that you was told by your PCP that there was nothing he can do and referred you to go this provider. You did not know this was not a plan provider and services would not be covered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 providers in this case are not network providers 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 comprehensive eye examination (92004) outpatient office visit for the evaluation and management (99204) and scanning computerized ophthalmic diagnostic imaging (92134) provided on September 11, 2019 by out of network (OON) providers.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for the primary care visit on August 9, 2019. We decided 
that the Plan does not have to waive the copayment for the specialist office visit on March 3, 2020.  
 
You asked the Plan to waive the copayments for the primary care visit and the specialist office visit. You say 
that you would like to appeal these claims. The Plan says that you have been charged the correct cost sharing 
amount. 
 
  
We decided that the Plan has to waive the copayment for the primary care visit on August 9, 2019.  
  
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. The plan did not submit the 2019 Evidence of Coverage to show the cost sharing 
amount for the primary care visit. This means that the plan has not shown that the copayment amount you are 
being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to 
waive the copayment for the primary care visit on August 9, 2020.  
 
We also decided that the Plan does not have to waive the copayment for the specialist office visit on 
March 3, 2020. 
 
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 the specialist office visit. Therefore, we decided that the Plan does not have to waive the 
copayment for the specialist office visit on March 3, 2020. 
 
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 the services (76604) provided on October 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.
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 76604 is "Ultrasound, chest (includes mediastinum), real time with image documentation". 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 services. Our reviewer says that the use of CPT code 76604 is not supported by the records provided. Our physician reviewer found that the medical records submitted do not include interpretation and report of chest ultrasound. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (76604) provided on October 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from February 6, 2020 to February 20, 2020.
You asked the Plan to waive the copayment for the SNF stay. You say that you were never informed that there would be a copayment. You say you were told your stay was covered by insurance. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $0 copayment per day, days 1-20 and a $160 copayment per day, days 21-42 for in-network Medicare-covered skilled nursing facility care, per benefit period. You have been asked to pay a $1,600 copayment for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. See chart below.
Dates of Service
Service
Copayment per Day
SNF Days
Number of Days
Member Liability
January 8, 2020 to January 24, 2020
SNF stay
$0
1-16
16
$0
February 6, 2020 to February 9, 2020
SNF stay
$0
17-20
4
$0
February 10, 2020 to February 20, 2020
SNF stay
$160
21-31
10
$1,600
Total
$1,600
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 SNF stay provided from February 6, 2020 to February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and bitewings
provided on February 10, 2020 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and bitewings. You say that you have
seen this provider for several years. You also say that you were not aware that your plan did not have OON
coverage. The Plan denied your request. The Plan says the treating provider does not participate in your Plan's
network.
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 by an OON provider. Therefore, we decided that the Plan does not have to pay
for the periodic oral evaluation, prophylaxis, and bitewings provided on February 10, 2020 by an OON
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673).
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673).