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

 
We decided that the Plan does not have to pay for the continued inpatient psychiatric care provided from March 
8, 2020, to March 11, 2020. 
 
You asked the Plan to pay for the continued inpatient psychiatric care. You say that the enrollee required this 
inpatient stay and was not able to be discharged. The Plan denied your request. The Plan says the enrollee 
could have been discharged to outpatient care on March 7. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient psychiatric care. Our 
reviewer says that the enrollee did not meet inpatient psychiatric criteria beyond the date in question. Our 
physician reviewer found This 62-year-old male was involuntarily admitted to the acute inpatient psychiatric 
hospitalization on March 4, 2020 with Mood Disorder Not Otherwise Specified, Ruler Bipolar Disorder, Rule 
out Posttraumatic Stress Disorder. Based upon review the records provided it was not expected this enrollee 
would improve in a reasonable period of time beyond the dates in question as he was not showing any 
dangerousness to self or others, no auditory or visual hallucinations and no abnormal behaviors. This patient 
was compliant with treatment. It did not appear medically necessary and reasonable to have psychiatric care 
provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he 
did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. The health plan?s 
denial of continued inpatient psychiatric services appears appropriate. This enrollee did not require inpatient 
mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others 
and did not have any auditory or visual hallucinations or behavioral issues. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the patients condition or for the purpose 
of diagnosis. Treatment beyond the date in question of March 8, 2020 forward could have been treated in a 
lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations and was not showing any behaviors being cooperative and compliant. 
 
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 continued inpatient psychiatric care have not been met. Therefore, we 
decided that the Plan does not have to pay for the continued inpatient psychiatric care provided from March 8, 
2020, to March 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis (L1851) suspension sleeve (L2397) and 
straight knee joint, heavy duty (L2385) provided April 15, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the medical records provided will show proof of 
medical necessity. The Plan denied your request. The Plan says the records do not support the service 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 a valid physician order, proof of delivery, or the itemized shipping/billing invoice 
relevant medical records which support medical necessity for the supplies provided in this case. The 
documentation submitted did not include a valid physician order, an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. 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 knee orthosis (L1851) suspension sleeve (L2397) and straight knee joint, heavy 
duty (L2385) provided April 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0637) provided to the enrollee on 
November 5, 2019. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. 
 
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 for the supplies provided in this case. There was no 
itemized shipping/billing invoice to indicate the services so the billed code could not be verified. 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 lumbar-sacral orthosis (L0637) provided to the enrollee on 
November 5, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 12, 2020. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a Medicare Health Plan must disclose to its members 
the benefits offered under the plan including applicable conditions and limitations, premiums and cost sharing 
such as copayments, deductibles and coinsurance. 
 
We looked at the file, the Plan's contract and Medicare rules. The Plan's contract clearly shows that prior 
authorization is needed for genetic testing. In this case, the file does not show that the provider sought prior 
authorization for the provided services. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on February 12, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 25, 2019 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the out of network nursing facility care. You say that the provider is a hospitalist 
with the group and depends upon the hospital staff to verify eligibility and to obtain the proper authorization 
from the enrollee's insurance company. You say that the services provided were medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage of out of network care have not been met. The Plan 
says that there was no network deficiency for the services provided and that the enrollee was not referred for 
the services by a participating provider. 
 
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 subsequent nursing facility care provided on July 
25, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay forthe mesial/distal wedge procedure provided on February 28, 2020.You asked the Plan to pay forthe mesial/distal wedge procedure. You say that an area in your mouth kept swelling badly. You also say that you are a diabetic, and the abscess had a higher chance of becoming infected.The Plan denied your request. The Plan says that this service is not covered under 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. The Plan covers the mesial/distalwedge procedure when the services are medically necessary and reasonable.We looked at this physician's review, the file, and Medicare rules. Meisal/distal wedge procedure is considered a periodontal surgery.The enrollee reasonably believed that this service would be covered.The EOC does not clearly state that specific periodontal surgery services are covered, nor does it clearly state that a mesial/distal wedge procedure is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of the mesial/distal wedge procedure have been met.Therefore, we decided that the Plan has to pay forthe mesial/distal wedge procedure provided on February 28, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on 
June 4, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis 
(L0648) provided to the enrollee on June 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided 
on May 19, 2020. 
 
You asked the Plan to pay for the CGP testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the CGP testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the Comprehensive Genomic Profile (CGP) testing provided on May 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on July 
9, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. 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 by the facility or the provider; 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 the domiciliary or rest home visit (99336) 
provided on July 9, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 7, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says screening tests are not 
covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on April 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a non-
participating provider on January 29, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you do not agree with this 
copayment. 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 $70 
copayment for physician/practitioner services/out-of-network/specialist.  
 
You have been asked to pay a $70 copayment for a specialist office visit. The correct copayment has been 
applied to the services that were provided. A specialist office visit falls within the physician/practitioner 
services/out-of-network/specialist benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
specialist office visit provided by a non-participating provider on January 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 6, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on May 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the nebulizer and supplies provided from 
February 20, 2020, to May 20, 2020. 
 
You asked the Plan to waive the coinsurance for the nebulizer and supplies. You say that you have not been 
using the nebulizer and should not be charged. The Plan denied your request. The Plan says that you pay a 20% 
coinsurance for these items. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a 20% coinsurance for the nebulizer and supplies. The nebulizer and supplies falls 
within the Durable medical equipment (DME) and related supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for the nebulizer and supplies provided from February 20, 2020, to May 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on May 6, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Comprehensive Genomic Profile (CGP) testing (i.e. Guardant-360 and NEXT-Generation) 
requires use of CPT 81479 (for the entire multi-test panel), and the appropriate DEX Z identifier entered 
adjacent in the comment narrative field. 
 
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 various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on May 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast biopsy provided on February 20, 
2020. 
 
You asked the Plan to waive the copayment for a breast biopsy. You say that you disagree with the surgical 
charges because you just had a needle inserted and no stitches. 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 $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities.  
 
You received a breast biopsy provided on February 20, 2020. A breast biopsy is considered an outpatient 
surgical procedure. Therefore, you are responsible to pay the $350 copayment.  
 
You have been asked to pay a $350 copayment for a breast biopsy. A breast biopsy falls within the outpatient 
surgery, including 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 copayment for a breast biopsy provided on February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general anesthesia, 26 extractions, 8 implants, immediate 
upper and lower dentures, and 2 bone replacement grafts provided from September 30, 2019, to October 17, 
2019. 
 
You asked the Plan to pay for the dental services. You say that the services you received were related to your 
medical condition. You say that you experienced bone loss due to medications that you have been on for 30 
years. You also say that the anesthesia was necessary due to the extensive procedure. The Plan denied your 
request. The Plan says the services you received are dental in nature. The Plan also says that dental services are 
not covered by Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule.  
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the general anesthesia, 26 
extractions, 8 implants, immediate upper and lower dentures, and 2 bone replacement grafts provided from 
September 30, 2019, to October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forurgently needed services provided on March 24, 2020.You asked the Plan to waive the copayment forurgently needed services. You say that you went to the urgent care because you had flu like symptoms and now you are being charged a 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 $50 copayment for urgently neededservices. You have been asked to pay a $50 copayment for urgently needed services. Urgently needed services fall within the urgently needed 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 forurgently needed services provided on March 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Guardant360 testing provided on May 6, 2020.You asked the Plan to pay forthe testing. The Plan denied your request. The Plan says the services were not billed correctly.The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one unit of CPT 81479 and the appropriate DEX Z-Code. We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plan does not have to pay forthe Guardant360 testing provided on May 6, 2020.