Persius/hicric huggingface dataset:
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 June 2, 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 the enrollee by an out-of-network provider 
on June 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 11, 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 to the 
code 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 May 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the complete upper denture provided on March 17, 
2020. 
 
You asked the Plan to pay more for the complete upper denture. You say that the dental coverage for 2020 was 
not enough to cover all the costs. You say that you lost what the Plan would have covered for 2019 so 
insurance should cover this debt. The Plan denied your request. The Plan says the maximum benefit has been 
used for the calendar year. 
 
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, you also have an annual maximum of 
$3,500. The Plan paid $3,500 toward your covered dental services in 2020. The remaining charges are your 
responsibility. Therefore, we decided that the Plan does not have to pay more for the complete upper denture 
provided on March 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the brace (L3960) provided March 2, 2020. 
 
You asked the Plan to pay for the brace. You say that the brace was medically necessary. The Plan denied your 
request. The Plan says the documentation does not support the services billed. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. The records do not show any discussion of need for the brace. 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 brace (L3960) provided March 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on March 6, 2020. 
 
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 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 on March 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for a knee surgery (29881) performed on May 
5, 2020. 
 
You asked the Plan to waive the cost-sharing for a knee surgery. You say that you were not aware of the 
deductible and shouldn't have to pay it. The Plan denied your request. The Plan says the correct cost-sharing 
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 $500 
deductible applicable to services provided to you at an ambulatory surgical center. Your contract also says that 
you must pay a $350 copayment for Medicare-covered surgery or other services provided to you at an 
ambulatory surgical center.  
 
You have been asked to pay $802.40, or $452.40 toward your $500 deductible plus a $350 copayment, for a 
knee surgery. Your deductible had not been met at the time a knee surgery was performed on May 5, 2020. A 
knee surgery falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers" 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 cost-sharing 
for a knee surgery (29881) performed on May 5, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on December 3, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that it is the facility's responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the facility 
or the provider. 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 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 December 3, 2019 
by an out of network (OON) provider.
Appeal type: Practitioner Services
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 April 14, 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 the enrollee by an out-of-network provider 
on April 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromuscular stimulator services (HCPCS E0745) provided 
to the enrollee on March 26, 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 codes classified as category "CR" have to be submitted with the correct DME modifier. 
 
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 HCPCS code E0745 is "Neuromuscular stimulator, electronic 
shock unit." 
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found he 
enrollee is reported to have left knee pain.  No detailed history, recent injury or surgery, associated symptoms, 
review of systems or physical examination, including weakness and/or deformity, has been documented.  There 
is no evidence of diagnostic evaluation (i.e. x-rays) or prescription therapy provision/response (i.e. prescription 
meds, injections, PT/OT).  Therefore, the documentation does not support the medical necessity or 
reasonableness of the provided service. 
 
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 neuromuscular stimulator services (HCPCS E0745) provided to the enrollee on March 26, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing care services provided on April 15, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for nursing care services. You say that the provider cannot deny services. You say it 
is the facility's responsibility to obtain prior authorization. The Plan denied your request. The Plan says 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 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 nursing care services provided on April 15, 2020 
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital physician services provided March 28, 
2017. 
 
You asked the Plan to pay for the inpatient hospital physician services. You say that you are asking for review 
all the documentation and provide additional payment for procedure codes 33533 and 33521 as you believe 
these codes should have been paid when the claim was initially processed. The Plan denied your request. The 
Plan says this claim was received past the 12 month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the inpatient hospital physician services was not filed until May 12, 2020. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the inpatient hospital physician services provided 
March 28, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wrist hand orthosis (L3916) provided on March 2, 2020. 
 
You asked the Plan to pay for the wrist hand orthosis. 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 indicate 
that the provider discussed a need for this item. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. The record does not include records to indicate the member's relevant diagnosis and other 
pertinent information including, but not limited to, duration of the member's condition, clinical course 
(worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic 
interventions and results, past experience with related items, etc. 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 wrist hand orthosis (L3916) provided on March 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction provided on February 5, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the extraction. You say that the enrollee needed dental care because his wisdom 
teeth were infected. You also say that this resulted in an extraction. The Plan denied your request. The Plan 
says these services were rendered by a non-participating provider. The Plan also says that any dental services 
received OON are not a covered benefit. 
 
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 
extraction provided on February 5, 2020 by an OON provider.
Appeal type: Practitioner Services
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 April 10, 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 the enrollee by an out-of-network provider 
on April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the echocardiography services you had on 
June 5, 2020. 
 
You asked the Plan to waive the copayment for the echocardiography services. You say that you thought this 
copayment would be waived due to COVID-19. The Plan denied your request. The Plan says you were charged 
this amount correctly.  The plan says that the cost sharing waiver it offered for COVID-19 did not include this 
service type.  The cost sharing waiver for COVID-19 only applies to primary care, behavioral health, and 
telehealth services. 
 
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 $125 
copayment for advanced imaging services.  
 
You have been asked to pay a $125 copayment for the echocardiography services. the echocardiography 
services fall within the advanced imaging 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 the echocardiography services you had on June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on February 
25, 2020. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you called the Plan in 
January and were told that the cost of an initial visit and dental examination, including x-rays, would be fully 
covered. You also say that neither you nor the enrollee were told at the time that the x-ray they were doing 
would result in an additional charge. The Plan denied your request. The Plan says a dental x-ray of the whole 
mouth was rendered, and the enrollee is responsible for the 50% coinsurance. 
 
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 enrollee is responsible for a 50% 
coinsurance for Class 2 Basic Services. The contract clearly lists intra oral x-ray image of the entire mouth 
under the Class 2 Basic Services category. Therefore, we decided that the Plan does not have to pay for the 
complete series of intraoral x-rays provided on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing care provided on April 25, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for nursing care. You say that it is not the doctor's responsibility to obtain the prior 
authorization, it is the facility's responsibility. The Plan denied your request. The Plan says prior authorization 
was not obtained by the provider or the facility; therefore, payment has been correctly denied. 
 
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 nursing care provided on April 25, 2020 by an out 
of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on June 
10, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were not satisfied 
with the care you were given. The Plan denied your request. The Plan says the copayment you are being 
charged is correct. 
 
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 $120 
copayment for emergency care.  
 
You have been asked to pay a $120 copayment for an emergency room visit. An emergency room visit falls 
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 copayment for an 
emergency room visit provided on June 10, 2020.  
 
Your complaint about the hospital not doing any testing 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home ventilator (E0466) provided on December 12, 2019. 
 
You asked the Plan to pay for a home ventilator. You say that this should be covered. The Plan denied your 
request. The Plan says a valid physician order has not been submitted. 
 
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 physician order and proof of delivery for the supplies provided in this case. 
Neither a physician order not a proof of delivery is present in the submitted documentation. 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 a home ventilator (E0466) provided on December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 24, 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 to the 
code 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 March 24, 2020.