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

 
We decided that the Plan does not have to pay for inpatient mental health services provided on March 5, 2020 
through April 10, 2020. 
 
You asked the Plan to pay for the inpatient mental health services. You say that you would like reconsideration 
because these services were medically necessary. The Plan denied your request. The Plan says the member 
does not meet criteria for inpatient mental health services beyond the approved date. 
 
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 inpatient mental health services. Our 
reviewer says that 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 illusions, auditory or visual 
hallucinations. 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 member's condition or for the purpose of diagnosis. Our physician reviewer found this member does not 
meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question and 
could have been treated in a lesser restrictive setting. 
 
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 inpatient mental health services have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient mental health services provided on March 5, 2020 through April 
10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiation oncology treatment provided on March 12, 2020. 
 
You asked the Plan to pay for the radiation oncology treatment. The Plan denied your request. The Plan says 
prior authorization was not obtained by the provider or facility. 
 
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 
radiation oncology treatment. 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 radiation oncology treatment provided on March 
12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gauze, non-impregnated, sterile, pad size 16 sq. in. or less, 
with any size adhesive border, each dressing (CPT Code A6219) and hydrogel dressing, wound filler, gel, per 
fluid ounce (CPT Code A6248) provided on March 30, 2020. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the DME was used in a SNF or hospital. Place of Service (POS) code 31 is used for services 
for patients in a covered Part A SNF stay. Under Consolidated Billing requirements SNFs submit all claims for 
residents for all services received under a covered Part A stay. As the provider billed for DME supplies with 
POS 31, and per the Medicare guidelines any DME furnished to inpatients in a covered Part A stay is included 
in the SNF PPS rate therefore; we find the Medicare rule for payment of this March 30, 2020, claim has not 
been met. If the provider determines that a billing error occurred during the initial submission of the denied 
claim, the plan would accept a submission of a corrected claim to consider services for payment. Therefore, we 
decided that the Plan does not have to pay for gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with 
any size adhesive border, each dressing (CPT Code A6219) and hydrogel dressing, wound filler, gel, per fluid 
ounce (CPT Code A6248) provided on March 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided March 
12, 2020 to March 16, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you need an 
explanation on what is going on with this bill because you ha doctor appointments within the dates of 
03/16/2020 and 03/17/2020. The Plan denied your request. The Plan says the plan verified that the enrollee was 
inpatient, therefore this claim was processed correctly per the plan benefits. 
 
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 $340 per 
day, days 1-5 $0 per day, days 6-90.  
 
You have been asked to pay for the inpatient hospital stay. The 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 the inpatient hospital stay 
provided March 12, 2020 to March 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on 
January 20, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the copayment was applied correctly. 
 
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 $400 
copayment for outpatient hospital facility services.  
 
Review of the file shows that you received outpatient hospital services on January 20, 2020. You have been 
asked to pay a $400 copayment for these services. These services fall within the outpatient hospital facility 
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 outpatient hospital 
services rendered on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology services provided on May 6, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for ophthalmology services. 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. The 
Plan says that there are multiple in-network providers available for 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 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 ophthalmology services provided on May 6, 2020 
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided on May 4, 2020. 
 
You asked the Plan to pay for the services. You say that  The Plan denied your request. The Plan says this 
provider is not eligible for payment for these services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services 
provided on May 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-share for non-covered ambulance mileage provided 
on February 14, 2020. 
 
You asked the Plan to waive the cost-share for non-covered ambulance mileage. You say that you do not agree 
with the extra charges. The Plan denied your request. The Plan says you requested to go to a specific facility 
considered to be further away from the closest hospital to you. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows that you requested to go to specific hospital, which caused the extra mileage. Due to 
this reason the provider has billed a charge for extra mileage for the transport totaling $485.43. This is 
considered as non-covered by Medicare guidelines and is not a covered benefit. 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-share for non-covered ambulance mileage provided on February 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cervical lymphadenectomy (38724) provided on May 8, 
2019. 
 
You asked the Plan to pay for the cervical lymphadenectomy. 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 38724 is cervical lymphadenectomy (modified radical 
neck dissection).  
 
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 cervical lymphadenectomy. Our 
reviewer says that the operative note states that no lymph nodes were removed. It also does not state that any 
major structures of the neck were identified and dissected out. The surgeon states he elevated flaps along the 
subplatysmal plane, but does not state he dissected the underlying structures. Our reviewer found the operative 
report does not show the provider performed a modified radical neck dissection. 
 
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 cervical lymphadenectomy have not been met. Therefore, we decided that 
the Plan does not have to pay for a cervical lymphadenectomy (38724) provided on May 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmological services: medical 
examination and evaluation, with initiation or continuation of diagnostic and treatment program provided on 
May 15, 2020. 
 
You asked the Plan to waive the copayment for ophthalmological services (92014). You say that you should 
not have a copayment. The Plan denied your request. The Plan says you have been charged this copayment 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment under Vision Care for a Medicare covered exam to treat an eye condition. Medicare generally does 
not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
You have been asked to pay a $40 copayment for ophthalmological services (92014). Ophthalmological 
services (92014) fall within the Vision Care for Medicare covered exam 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 ophthalmological services: medical examination and evaluation, 
with initiation or continuation of diagnostic and treatment program (92014) provided on May 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasonic guidance for needle placement provided on 
February 6, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the out of network ultrasonic guidance for needle placement. You say that your 
physician owns the equipment and performed both the professional and technical components of this 
procedure. You say that the records support the charge in dispute. The Plan denied your request. The Plan says 
the out of network services were not authorized. The Plan says that the enrollee was referred by a doctor who 
also does not work with the enrollee's plan. 
 
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 ultrasonic guidance for needle placement provided 
on February 6, 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 by a 
participating provider on January 8, 2020 to January 13, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with 
this stay because you say that the stay was because of the doctor's mistake. 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 $250 
copayment per day for days 1-7. There is a $0 copayment for days 8-90 for inpatient hospital coverage.  
 
You have been asked to pay a $250 copayment per day for days 1-5 for an inpatient hospital stay. The total 
amount you are being asked to pay is $1,250 ($250 x 5 days = $1,250). An inpatient hospital stay falls within 
the inpatient hospital coverage 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 by a participating provider on January 8, 2020 to January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis (Tdap) 
vaccine (90715), administration (90471), and a second administration of a pneumococcal vaccine (G0009) 
provided on October 9, 2019. 
 
You asked the Plan to pay for a Tdap vaccine, administration, and a second administration of a pneumococcal 
vaccine. You say that these vaccines are supported in these records. The Plan denied your request. The Plan 
says the Tdap vaccine is the responsibility of the enrollee's prescription drug plan and the second 
pneumococcal conjugate vaccine exceeds the MUE. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a Tdap vaccine, 
administration, and a second pneumococcal conjugate vaccine. The Plan follows the same rules. The rules also 
say that claims submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be 
denied. 
 
 
 
In this case, the MUE for CPT code G0009 is 1. You billed this code twice, exceeding the MUE. The records 
also do not show that the enrollee had been injured or directly exposed to any illness related to a Tdap vaccine.  
Therefore, we decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular 
pertussis (Tdap) vaccine (90715), administration (90471), and a second administration of a pneumococcal 
vaccine (G0009) provided on October 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT of the Thorax (71250) provided on November 23, 
2019. 
 
You asked the Plan to pay for the CT of the Thorax. You say that you would like reconsideration because this 
service was denied in error. The Plan denied your request. The Plan says Original Medicare would be 
responsible for payment of all Medicare covered services related or unrelated to the member's terminal 
condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 8, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the CT of the Thorax 
(71250) provided on November 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth services provided by a 
participating provider on April 3, 2020. 
 
You asked the Plan to waive the copayment for telehealth services. You say that you do not feel like the 
services that were provided warrant the copayment that was applied. 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 $40 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $40 copayment for physical therapy telehealth services.  Physical therapy 
telehealth services fall within the outpatient rehabilitation 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 telehealth services provided by a participating provider on April 3, 2020.
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 September 30, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 September 30, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Decipher Oncology mRNA Gene Expression provided on 
June 17, 2020. 
 
You asked the Plan to pay for the Decipher Oncology mRNA Gene Expression. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Decipher Oncology gene expression is only covered 
for certain indications. 
 
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 Decipher Oncology mRNA Gene 
Expression. Our reviewer says that the documentation does not support that the rendered services were 
medically reasonable or necessary. Our physician reviewer found the enrollee the test billed was for very low 
to intermediate risk, the test was done for high risk (Gleason Score 4+5=9). The review has determined that the 
enrollee does not have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of 
Decipher Oncology mRNA Gene Expression. The Decipher Oncology mRNA Gene Expression is not 
considered the standard of care for the treatment of this enrollee's condition. Given the Gleason score of 4+5=9 
it was not medically necessary and reasonable for this enrollee to have Decipher Oncology mRNA Gene 
Expression as received. 
 
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 Decipher Oncology mRNA Gene Expression have not been met. Therefore, 
we decided that the Plan does not have to pay for the Decipher Oncology mRNA Gene Expression provided on 
June 17, 2020.