Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for outpatient mental health services provided 
by an out-of-network provider on August 8, 2019, to February 28, 2020. 
 
You asked the Plan to waive the deductible for outpatient mental health services. You say that you do not agree 
with this amount. The Plan denied your request. The Plan says the correct deductible has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible for outpatient mental health care/out-of-network.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
mental health care/out-of-network. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $1,000 deductible for outpatient mental health care/out-of-network. This cost sharing is a 
contractual obligation that had not been met at the time outpatient mental health services was received on 
August 8, 2019 to February 28, 2020. The total amount you are being asked to pay is $347.68 ($146.62 + 
$52.77 + $148.29 = #347.68). Therefore, we decided that the Plan does not have to waive the deductible for 
outpatient mental health services provided by an out-of-network provider on August 8, 2019, to February 28, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the infusion therapy services you received 
from March 5, 2020, to March 12, 2020. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible 
for the cost share. 
 
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 $295 
copayment for surgery or other services provided to you at an outpatient hospital, including but not limited to 
hospital or other facility charges and physician or surgical charges.  
 
Review of the file shows that you received three outpatient infusion therapy services from March 5, 2020, to 
March 12, 2020. Per your contract with the Plan, there is a $295 copayment for each of these services. 
However, the provider billed each service for $128, totaling $384. Since the billed amount is less than the 
copayment amount, you have been asked to pay the lesser amount. 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 infusion therapy services you received from March 5, 2020, to March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing (CPT 81291) provided on June 9, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that Genetic testing for these genes for all risk 
factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered 
except for pregnant patients.  
 
We looked at the file and Medicare rules. The requested testing is non-covered according to L36400. 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 genetic testing (CPT 81291) provided on June 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 29, 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 procedure code 81479 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 81479 is unlisted molecular pathology procedure. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, there is no narrative 
explanation of the testing represented by this code. 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 laboratory services rendered on January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse 50% of the allowed amount for the dental services 
provided from June 4, 2020, to June 25, 2020. 
 
You asked the Plan to reimburse 50% of the allowed amount for the dental services. You say that you needed 
to see this dentist due to his expertise and your health conditions. You say that you were aware the dentist was 
out of network. You say that you were expecting reimbursement of 50% for the services you received. You 
also say that you should not have to see a dentist you do not know as someone in your area passed away from 
an infection after having a tooth filled last year. The Plan denied your request. The Plan says if you receive care 
from a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the 
services you receive. 
 
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 
reimburse 50% of the allowed amount for the dental services provided from June 4, 2020, to June 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation and prophylaxis provided 
on June 8, 2020. 
 
You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that the booklet 
doesn't note any difference if the dentist is in-network or not. You say that the remainder of the bill should be 
paid. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 Plan is only obligated to pay the 
allowed amount for the periodic oral evaluation and prophylaxis when received from an out-of-network 
provider. You are responsible for the difference between the billed and allowed amount. Therefore, we decided 
that the Plan does not have to pay more for the periodic oral evaluation and prophylaxis provided on June 8, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug infusion supplies provided for May 19, 2020, 
through May 25, 2020. 
 
You asked the Plan to pay for the infusion supplies. You say that the documentation supports payment of this 
claim. The Plan denied your request. The Plan says the POD documentation does not link the delivery ticket to 
the shipping confirmation. 
 
The Plan must follow Medicare rules. Medicare rules say that POD must include a delivery ticket with an 
itemized description of the items provided and confirmation of receipt by the enrollee. The delivery ticket must 
be clearly linked to the shipping confirmation by some method, such as the delivery service's package 
identification number. 
 
The delivery ticket included in the file does not have any identifying information, such as a tracking number, to 
link it to the shipping confirmation from the delivery service. Therefore, we decided that the Plan does not have 
to pay for the drug infusion supplies provided for May 19, 2020, through May 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on review of the medical records, you do not meet the CMS coverage criteria 
for an IRF admission based on lack of medical and nursing needs and current functional status. You are with 
debility from recent illness but are generally medically stable. There is no evidence of medical issues that 
require monitoring by an inpatient rehab physician three times a week. The documentation does not support 
that there is a need for an intensive therapy program with three (3) hours a day and an interdisciplinary 
approach to rehab care. At your current level of function, you are not expected to make a significant functional 
recovery in a reasonable period to be discharged to live alone. You do not meet the CMS coverage criteria for 
an IRF admission. Your rehab needs can be met in an alternate, less intense setting such as in a skilled nursing 
facility (SNF). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic parenteral drug (D9610) provided on June 9, 
2020. 
 
You asked the Plan to pay for the therapeutic parenteral. You say that deep sedation was used due to the extent 
of the services that were rendered and the enrollee's past medical history. You also say that post-operative 
nausea treatment was required. The Plan denied your request. The Plan says therapeutic parenteral drug is not 
listed as a covered service. 
 
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 
therapeutic parenteral drug (D9610) provided on June 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for automatic external defibrillator, garment with integrated 
electrocardiogram analysis (K0606) provided February 14, 2019. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that please reconsider for payment 
on late filing. You are requesting forgiveness on the error on your behalf. The Plan denied your request. The 
Plan says this claim was not received within 12 months or 1 calendar year from the date when the services were 
rendered. 
 
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 automatic external defibrillator was not filed until May 14, 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 automatic external defibrillator, garment with 
integrated electrocardiogram analysis (K0606) provided February 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dermatology services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the OON dermatology care. You say that you have places on your skin that 
had high exposure to chemical during your 37-year career at a chemical plant. You believe that you need to 
have your skin checked to rule out cancer. The Plan denied your request. The Plan says review of the network 
shows that there are several in-network dermatologists in your area who can provide the evaluation you require. 
As such, there is no need for OON referral. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the dermatology services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99202) and biopsy services (40490, D9239) 
provided from April 21, 2020, to May 4, 2020. 
 
You asked the Plan to pay for an office visit and biopsy services. You say that you should receive 
reimbursement for your out-of-pocket costs. The Plan denied your request. The Plan says services from opt-out 
providers are not covered. 
 
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 
an office visit (99202) and biopsy services (40490, D9239) provided from April 21, 2020, to May 4, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to waive the balance bill amount for the periodic oral evaluation, prophylaxis, 
bitewing x-rays and unspecified adjunctive procedure. We decided that the Plan does not have to waive the 
coinsurance for the periodic oral evaluation, prophylaxis, bitewing x-rays and unspecified adjunctive 
procedure.  
 
You asked the Plan to pay more for the periodic oral evaluation, prophylaxis, bitewing x-rays and unspecified 
adjunctive procedure. You say that you received a denial of payment for the whole amount, but you only 
requested reimbursement of $206. The Plan says the claim processed correctly. 
 
We decided that the Plan has to waive the balance bill amount for the periodic oral evaluation, 
prophylaxis, bitewing x-rays and unspecified adjunctive procedure.  
 
The Plan contract does not say that you would be expected to be balance billed for dental services from an out-
of-network provider. This means that you can only be asked to pay the proper coinsurance for these services.  
 
Service Billed Amount Allowed 
Amount 
20% or 70% 
Coinsurance 
Balance Bill 
Amount 
Correct Member 
Liability 
Oral Evaluation $50 $23 $4.55 $27.23 $4.55 
Prophylaxis $94 $32.08 $6.42 $61.92 $6.42 
X-Rays $62 $33.12 $6.62 $28.88 $6.62 
Adjunctive 
Procedure 
$75 $75 $52.50  $52.50 
TOTAL:    $118.03 $70.09 
 
Therefore, we decided that the Plan has to waive the balance bill amount of $118.03 for the periodic oral 
evaluation, prophylaxis, bitewing x-rays and unspecified adjunctive procedure.  
 
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transportation provided on April 11, 2020. 
 
You asked the Plan to pay for ambulance transport. You say that the enrollee only had one transportation on 
this date of service following hospital discharge. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the enrollee was in an inpatient hospital status for this date of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance services are separately reimbursable 
only under Part B, and the movement of an inpatient is covered as an inpatient hospital or CAH service with 
payment made under Part A for the service.  
 
We looked at the file and Medicare rules. This ambulance transportation is not separately payable because the 
enrollee was a hospital inpatient at the time of service. Based on this information, we decided that Medicare 
rules for coverage of ambulance transport have not been met. Therefore, we decided that the Plan does not have 
to pay for ambulance transportation provided on April 11, 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 
June 15, 2020 by an OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you have a $300 
allowance. You also say that you will never use the whole $300 allowance. The Plan denied your request. The 
Plan says these services were rendered by an OON provider. 
 
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 
fully covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation and prophylaxis provided on June 15, 2020 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the cataract surgery (66984) provided on 
February 13, 2020 and March 5, 2020. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance was applied correctly to the 
services 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 20% 
coinsurance for outpatient surgery, including each Medicare-covered outpatient hospital visit and hospital 
outpatient surgical facility.  
 
You have been asked to pay $903.18 ($2,257.93 Plan allowed amount x 20% coinsurance=$451.59 x 2) for the 
outpatient surgeries provided in an outpatient hospital. 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 cataract surgery (66984) provided on February 13, 2020 and March 5, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nine (9) home health skilled nursing visits and six (6) 
home health physical therapy visits. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer 
found in order to require Home health care skilled services, the member must be confined to the home, under 
the care of a physician, and receiving services under a plan of care established and periodically reviewed by a 
physician. Additionally, the member must be in need of skilled nursing care on an intermittent basis or physical 
therapy or speech-language pathology; or have a continuing need for occupational therapy. Being homebound 
means leaving home is a major effort. In this case, the documentation doesn't support that you require skilled 
nursing services or skilled physical therapy services to provide treatment that is medically necessary. You do 
not require skilled nursing or physical therapy services to effectively provide treatment, care, and/or services in 
order to improve your condition, perform a maintenance program to maintain the patient's condition and/or 
prevent deterioration. You have been medically stable without any re-admissions to the hospital. There is no 
documentation that you have had any decline in function or new medication changes. The visits approved by 
the health plan are adequate to teach a home exercise program, but further skilled nursing or physical therapy 
services are not medically necessary. 
 
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 pre-approve nine (9) home health skilled nursing visits and six (6) home health physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on March 5, 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 procedure codes J3411, J3415, and J3490 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 J3411 is injection, thiamine HCl, 100 mg. The definition 
of code J3415 is injection, pyridoxine HCl, 100 mg. The definition of code J3490 is unclassified drugs. 
 
We find that CPT codes J3411, J3415, and J3490 are not supported in the medical record. Specifically, the 
documentation shows that nutria-pharmaceutical blend was administered and the codes cannot be billed 
separately. 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 services rendered on March 5, 2020.