Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on April 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the coverage rules are 
not met. 
 
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 documentation of the ordering 
physician's intent that the tests 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 April 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services. 
 
You asked the Plan to waive the copayment for lab services. You say that you disagree with the charges 
because the labs were taken during an annual wellness exam. 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 $10 
copayment for lab services.  
 
You have been asked to pay a $10 copayment for lab services. Lab services fall within the outpatient diagnostic 
tests and therapeutic services and 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 copayment 
for lab services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe durable medical equipment (DME) as defined by codes L1971, L3170, L1851, L2397, L3960, L3916 and A4595.You asked the Plan to pay forthe DME. You say that the enrollee requires the DME.The Plan denied your request. The Plan says the documentation does not indicate services are necessary.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 deliveryto support medical necessity for the supplies provided in this case. The submitted invoice indicates the item was shipped on April 182020 and delivered on April 23 2020; however, the billed date of service is March 25, 2020. In addition, the documentation submitted did not include an itemized shipping/billing invoice from the billing provider to indicate the specific supplies. 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 forthe durable medical equipment (DME) as defined by codes L1971, L3170, L1851,L2397, L3960, L3916 and A4595.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive thecopayment forinpatient mental health care you received from November 21, 2019, through November 25, 2019.You asked the Plan to waive the copayment forthe inpatient mental health services. You say that you shouldn't have to pay this copayment because you do not believe you needed to be admitted.The Plan denied your request. The Plan says you were charged this copayment correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (suchas copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 copayment per day for days 1-7 for inpatient mental health care. You have been asked to pay a $290 copayment per day for the inpatient mental health services. This copayment applies regardless of the reason for your admission. 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 forinpatient mental health care you received from November 21, 2019, through November 25, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the Upper GI Endoscopy (43239) provided. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $150 
copayment for each in-network Medicare-covered outpatient surgery or procedure at an outpatient hospital 
facility or ambulatory surgical center.  
 
You have been asked to pay a $150 copayment for the in-network Medicare-covered procedure provided at an 
outpatient ambulatory surgical center. 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 Upper GI 
Endoscopy (43239) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe podiatry visit you had on June 19, 2020.You asked the Plan to waive the copayment forthe podiatry visit. You say that you shouldn't have to pay a copayment because you were there less than five minutes.  You say that the doctor didn't do anything for you.The Plan denied your request. The Plan says you were 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 $35 copayment for podiatry visits. You have been asked to pay a $35 copayment for the podiatry visit. This copayment applies regardless of how long the visit lasts. 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 forthe podiatry visit you had onJune 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit and a CT scan 
provided by a participating provider on October 15, 2019 and November 2, 2019. 
 
You asked the Plan to waive the copayment for an emergency room visit and a CT scan. You say that you do 
not agree with these services. The Plan denied your request. The Plan says the correct copayments have 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 $120 
copayment and a $175 copayment for emergency care/in-network and outpatient diagnostic tests/in-
network/advanced imaging services/outpatient hospital.  
 
You have been asked to pay a $120 copayment for an emergency room visit and a $175 copayment for a CT 
scan. The total amount you are being asked to pay is $295 ($120 + $175 = $295). An emergency room visit 
falls within the emergency care/in-network benefit category and a CT scan falls within the outpatient diagnostic 
tests/in-network/advanced imaging services/outpatient hospital 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 and a 
CT scan provided by a participating provider on October 15, 2019 and November 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the follow-up visit you had with a 
urologist and urinalysis services you had on June 16, 2020. 
 
You asked the Plan to waive the copayments for the urology visit and urinalysis services. You say that since 
this was just a follow-up visit, no copayment should apply. The Plan denied your request. The Plan says you 
were charged this cost sharing 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 $35 
copayment for specialist visits and a $10 copayment for lab services.  
 
You have been asked to pay a $35 copayment for the urology visit and $3.48 for the urinalysis services. You 
have only been asked to pay $3.48 for the lab services because the allowed amount for this service is less than 
your $10 copayment for lab services. 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. These copayments apply regardless of the reason for the visit. Therefore, we decided that the Plan 
does not have to waive the copayments for the follow-up visit you had with a urologist and urinalysis services 
you had on June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 10, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 physician's services provided on January 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis (L1851), a suspension sleeve (L2397), and 
straight knee joint (L2385). 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like reconsideration 
because these supplies are medically necessary. The Plan denied your request. The Plan says the documentation 
submitted did not include an itemized shipping/billing invoice to indicate the specific supplies 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. The record does not 
include an itemized shipping/billing invoice to indicate what supplies were delivered. Additionally, the 
documentation submitted does not include a proof of delivery ticket 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), a suspension sleeve (L2397), and 
straight knee joint (L2385).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the rituximab, methylprednisolone sodium 
succinate and diphenhydramine HCl injections provided to the enrollee on June 5, 2019. 
 
You asked the Plan to waive the coinsurance for the injections. The Plan denied your request. The Plan says 
that the claim processed 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for the injections. The injections fall within the Medicare Part 
B prescription drugs 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 rituximab, 
methylprednisolone sodium succinate and diphenhydramine HCl injections provided to the enrollee on June 5, 
2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a 
participating provider on June 23, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you were told to have 
this colonoscopy by your doctor. 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 $225 
copayment for outpatient surgery/in-network.  
 
You have been asked to pay a $225 copayment for a diagnostic colonoscopy. Since the colonoscopy that was 
provided was diagnostic in nature, the correct copayment has been applied. A diagnostic colonoscopy falls 
within the outpatient surgery/in-network 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 diagnostic colonoscopy provided by a participating provider on June 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lower extremity magnetic resonance imaging (MRI) 
rendered on April 15, 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 the billed diagnosis does not match the billed procedure. 
 
The Plan must follow Medicare rules. The rules say that anatomical modifiers are required for procedures 
performed on different anatomical sites. The rules say that claims must be billed with a proper diagnosis code. 
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure code 73721-26 with the 
LT anatomical modifier and diagnosis code L97.509 (non-pressure chronic ulcer of other part of unspecified 
foot with unspecified severity). The diagnosis code for unspecified foot does not match the billing with the -LT 
modifier and is not payable as billed. Therefore, we decided that the Plan does not have to pay for the lower 
extremity magnetic resonance imaging (MRI) rendered on April 15, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on December 14, 2019, through December 16, 2019. 
 
You asked the Plan to waive the copayment for an emergency room 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 $120 
copayment for emergency care/in-network.  
 
You have been asked to pay a $120 copayment for an emergency room visit. An emergency room visit falls 
within the emergency care/in-network 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 by a participating provider on December 14, 2019, through December 16, 
2019.  
 
This appeal only looks at the emergency room visit. Please contact the Plan for all other services being 
appealed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (CPT 99153 and HCPCS G0500) 
provided to the enrollee on October 9, 2019. 
 
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 the documentation submitted did not indicate the presence of an independent trained observer to 
assist in the monitoring of the patient's level of consciousness and physiological status; therefore, the billed 
service cannot be verified. 
 
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 the denied codes is: 
 
CPT 99153: 
 
Moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; each additional 15 minutes intraservice time (list separately in addition to code for 
primary service) 
 
HCPCS G0500: 
 
Moderate sedation services provided by the same physician or other qualified health care professional 
performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; initial 15 minutes of intra-service time; patient age 5 years or older 
 
 
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 the 
medical records provided do not include documentation of an independent trained observer to assist in the 
monitoring of the enrollee's level of consciousness and physilogical status; therefore these services cannot be 
verified. In addition, primary CPT code G0500 was denied by the health plan, so CPT 99153 is not eligible for 
separate reimbursement. 
 
 
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 moderate sedation services (CPT 99153 and HCPCS G0500) provided to the enrollee on 
October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided byonNovember 19, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan saysall non-emergent services received with a non-Plan provider require approval by the Plan prior to the services being rendered.The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.The services at issue in this appeal were not provided in an emergency or urgent care situation. These serviceswere not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on November 19, 2019.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical preparation or creation of recipient site by excision of open 
wounds (CPT Code 15004) and formation of direct or tubed pedicle, with or without transfer; eyelids, nose, 
ears, lips, or intraoral  (CPT Code 15576). 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the services are not supported by the records. 
 
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 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 physician reviewer found the documentation in the Operative Report 
supports the creation of a wound on the nose, first 100 sq cm, in preparation for flap reconstruction. The 
documentation in the Operative Report supports the formation of a pedicle with transfer of a nasolabial flap on 
the nose. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical preparation or creation of recipient site by excision of open wounds (CPT Code 15004) and formation 
of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral  (CPT Code 15576).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on March 16, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says no 
authorization was 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 
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 a domiciliary, rest home visit provided on March 16, 2020.