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

 
We decided that the Plan does not have to pay for physician services provided on January 17, 2020 to February 
14, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says there are in-network providers available 
for these services. The Plan says that prior authorization was not obtained. 
 
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 physician services provided on January 17, 2020 
to February 14, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 and G0480 provided on 
November 4, 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. 
 
We find that CPT codes 80307 and G0480 are not supported in the medical record. Specifically, the 
documentation submitted did not include a valid physician order/lab requisition or medical records signed by 
the ordering physician stating exactly what tests were to be performed. Based on this information, we decided 
that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing coded 80307 and G0480 provided on November 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on February 25, 
2020. 
 
You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93010 is electrocardiogram, routine ECG with at least 12 
leads; interpretation and report only. 
 
We find that CPT code 93010 is not supported in the record. Specifically, the record indicates that an 
emergency department evaluation and management service was billed on the same date of service. The file 
does not include any medical records to determine if the electrocardiogram, routine ECG with at least 12 leads; 
interpretation and report only was rendered on this date of service. Based on this information, we decided that 
Medicare rules for coverage of the electrocardiogram have not been met. Therefore, we decided that the Plan 
does not have to pay for an electrocardiogram (93010) provided on February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic image (D0350) provided on 
January 7, 2020. 
 
You asked the Plan to pay for the 2D oral/facial photographic image. You say that you feel the provider should 
have informed you that you would be charged for this service. You also say that you should not be responsible 
for paying $360.00 for a service you did not know you would be charged for. The Plan denied your request. 
The Plan says this service is not covered by your dental 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 2D 
oral/facial photographic image (D0350) provided on January 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided during a cystoscopy
(CPT 52000).
You asked the Plan to pay for the assistant surgeon services. You say that the services were ordered by a
participating physician. You say that the claim should be reprocessed and additional payment should be issued
for the surgical assistant services rendered. The Plan denied your request. The Plan says the services in dispute
are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator
of 1, assistant surgeon services are not covered.
We looked at the file and Medicare rules. In this case you are disputing assistant surgery services with CPT
code 52000. The Medicare Fee Schedule Databased contains a surgical indicator of 1 for this procedure. This
means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid.
Based on this information, we decided that Medicare rules for coverage of the assistant surgeon services have
not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services
provided during a cystoscopy (CPT 52000).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing provided on June 12, 2019. 
 
You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory 
requisition. The Plan denied your request. The Plan says that the denial of payment for this service is correct, 
because the documentation does not include a valid physician order, lab requisition, or medical records to 
support the code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted includes a valid physician order for the 
specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage 
of drug test have been met. Therefore, we decided that the Plan has to pay for drug testing provided on June 12, 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the amalgam (D2150) and resin-based composite (D2332) 
provided on April 13, 2020. 
 
You asked the Plan to pay for the amalgam and resin-based composite. You say that your insurance card says 
you are eligible for dental services, and do not understand why these services you had are not covered. The 
Plan denied your request. The Plan says these services are not covered by the Plan. The Plan also says that you 
did not opt to purchase a supplemental dental benefit package. 
 
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 
amalgam (D2150) and resin-based composite (D2332) provided on April 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advanced life support supplies (A0398) provided on January 
14, 2020. 
 
You asked the Plan to pay for the ambulance supplies. You say that you would like reconsideration because 
these services were medically necessary for your condition. The Plan denied your request. The Plan says 
Medicare does not make separate payment for ambulance supplies. 
 
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 A0398 is not supported in the record. Specifically, Medicare does not make separate 
payment for ambulance supplies. Based on this information, we decided that Medicare rules for coverage of the 
ambulance supplies have not been met. Therefore, we decided that the Plan does not have to pay for advanced 
life support supplies (A0398) provided on January 14, 2020.  
 
Please note, the Plan has confirmed that you are not responsible for this payment because it is included in the transport 
fee, which has been approved for payment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a sacroiliac steroid injection provided on May 29, 2019.
You asked the Plan to pay for the sacroiliac steroid injection. The Plan denied your request. The Plan says that 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 service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for a sacroiliac steroid injection provided on May 29, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided October 2, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. 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 drug testing services provided October 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on February 6, 2020.
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 Guardant360 testing is not supported in the medical record. Specifically, this service should be billed with code 81479. In addition, the appropriate DEX Z Code identifier should be entered adjacent in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on March 16, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that you are unhappy with the service 
provided and feel that you should not owe the copayment. 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 $15 
copayment for services obtained by a primary care provider.  
 
You have been asked to pay a $15 copayment for an office visit. An office 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 an office visit provided on March 16, 2020.  
 
We note your complaint that you are unhappy with the service the doctor provided. Your complaint is a 
grievance that must be answered by the health plan. Medicare does not permit us to make a decision about 
these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on April 29, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 you by an out-of-network provider on April 
29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on 
November 7, 2019. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were not aware 
that the dentist, in the same location, was not part of the Medicare Advantage network. You also say that the 
providers are all in the same dental office. The Plan denied your request. The Plan says the treating provider 
has opted out of participation with Medicare Advantage. The Plan also says that your plan does not cover 
services billed by providers that have opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the periodic oral evaluation and prophylaxis provided on November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided a participating provider on February 14, 2020 to February 25, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that this was not a surgery. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for physician services/in-network/surgery services/specialist's office. You have been asked to pay a total of $97.37 ($50 + $47.37 = $97.37) for two outpatient surgeries. The correct copayment has been applied to the services that were provided. An outpatient surgery falls within the physician services/in-network/surgery services/specialist's office 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 an outpatient surgery provided by a participating provider on February 14, 2020 to February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on February 6, 
2020. 
 
You asked the Plan to pay for the dental services. You say that you have been getting periodontal maintenance 
done for twenty (20) years and it is considered routine. The Plan denied your request. The Plan says the service 
is not a covered benefit under the 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. This service is not listed in your dental certificate as a covered benefit; 
therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for periodontal 
maintenance (D4910) provided on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services you received from December 2, 
2019, to December 30, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the benefit limit was 
reached. 
 
The rules say that acupuncture services are not covered by Medicare. However, the Plan offers an acupuncture 
benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan 
covers up to 24 acupuncture visits per year.  
 
We looked at the file and the Plan?s rules. The records show that the acupuncture maximum benefit was 
reached on November 18, 2019. The requested services exceed the benefit limit. Based on this information, we 
decided that the Plan?s rules for coverage of the acupuncture services have not been met. Therefore, we decided 
that the Plan does not have to pay for the acupuncture services you received from December 2, 2019, to 
December 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 11, 2020 to February 14, 2020 by an out of network (OON) 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 an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 11, 2020 to February 14, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
February 24, 2020 to March 4, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
charges because you waited for a procedure to happen that never happened. 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 $150 
copayment each day for days 1-7 for inpatient hospital care.  
 
You had an inpatient hospital stay from February 24, 2020 to March 4, 2020. Therefore, you are responsible to 
pay a $150 copayment for days 1-7 (February 24, 2020 to March 1, 2020). $150 (copayment) x 7 (inpatient 
days) = $1,050. 
 
You have been asked to pay the total copayment amount of $1,050 for an inpatient hospital stay. An inpatient 
hospital stay 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 an inpatient hospital stay provided from February 24, 2020 to March 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased by the enrollee on November 2, 
2019 from an out-of-network provider. 
 
You asked the Plan to pay for the hearing aids. You say that the member purchased the hearing thinking they 
would be reimbursed by the Plan. The Plan denied your request. The Plan says you do not have out-of-network 
benefits for hearing aids. 
 
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. 
 
Review of the file show that the enrollee purchased hearing aids on November 2, 2019 from an out-of-network 
provider. 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 hearing aids purchased by the enrollee on 
November 2, 2019 from an out-of-network provider.