Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for cataract surgery (66984) performed on 
May 8, 2019 and May 22, 2019. 
 
You asked the Plan to waive the coinsurance for cataract surgery. You say that you should not be charged this 
coinsurance. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for each Medicare-covered outpatient hospital facility or ambulatory surgical center visit.  
 
You have been asked to pay $749.16 or two payments of $374.58, which is 20% of the Plan-allowed amount 
$1,872.88, for cataract surgery. Cataract surgery 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 coinsurance for cataract surgery (66984) performed on May 8, 2019 and May 22, 
2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the PET/CT scan provided on February 
19, 2020 billed with diagnosis code C32.9. 
 
You asked the Plan to pay for the PET scan interpretation. You say that the medical records support the need 
for this imaging. The Plan denied your request. The Plan says this claim was not reported with an appropriate 
diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that PET imaging for oncologic conditions have 
certain diagnosis codes for which they can be covered.  
 
Diagnosis code C32.9 is not listed among the covered diagnosis codes. C32.0, C32.1, C32.2, C32.3, or C32.8 
are appropriate. Using the unspecified code is not appropriate according to the rules. Therefore, we decided that 
the Plan does not have to pay for the interpretation of the PET/CT scan provided on February 19, 2020 billed 
with diagnosis code C32.9.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 27, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for urology services. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-
network with the Plan and authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 medical services provided on February 27, 
2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the gradient compression wrap provided on March 18, 2020. 
 
You asked the Plan to pay for the gradient compression wrap. You say that these services were medically 
necessary and were ordered by a plan provider. The Plan denied your request. The Plan says that this provider 
is not contracted with the member's Medicare plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, in its initial file sent to us, the Plan failed to provide any 
documentation beyond the appeal documentation that you submitted to them supporting their denial.  The Plan 
failed to provide any documentation regarding authorization requests, reconsideration documentation, medical 
records, or even a correct Evidence of Coverage.  We reached out to the plan to try to get some of this 
information, but limited information was provided.  The plan contends that the provider of the item in question 
was not a plan provider.  However, the plan failed to provide any evidence, via the appropriate applicable 
Evidence of Coverage for this enrollee, showing that non-contracted care is not covered under this enrollees 
plan. Furthermore, it appears as though the item in question was ordered directly by the patient?s physician.  
The Plan failed to provide any evidence as to whether or not this ordering provider was a contract provider with 
the plan. Without this required evidence, we find that the Plan has not substantiated its denial. Therefore, we 
decided that the Plan has to pay for the gradient compression wrap provided on March 18, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ear wax removal provided on February 19, 2020 billed 
with CPT code 69210-59. 
 
You asked the Plan to pay for the ear wax removal. You say that the records support the billed code. The Plan 
denied your request. The Plan says the records do not adequately document the ear wax removal. 
 
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 69210 is Removal impacted cerumen requiring 
instrumentation, unilateral. 
 
We find that CPT code 69210 is not supported in the medical record. Specifically, the progress note does not 
include any actual documentation regarding the performance of this service. The code is noted in the Plan 
section of the SOAP note but there is no clear statement that indicates that the ear wax was removed using 
instrumentation. Based on this information, we decided that Medicare rules for coverage of the ear wax 
removal have not been met. Therefore, we decided that the Plan does not have to pay for the ear wax removal 
provided on February 19, 2020 billed with CPT code 69210-59.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the aminophyllin injection services coded J0280 provided on 
September 14, 2019. 
 
You asked the Plan to pay for the aminophyllin injection services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 J0280 is Injection, aminophyllin, up to 250 mg. 
 
We find that CPT code J0280 is not supported in the medical record. Specifically, the documentation submitted 
does not support the units billed for this service. Three (3) units were billed. Additional information regarding 
the dosage administered was not provided. Based on this information, we decided that Medicare rules for 
coverage of the aminophyllin injection services have not been met. Therefore, we decided that the Plan does 
not have to pay for the aminophyllin injection services coded J0280 provided on September 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat 
exchanger provided on February 18, 2020. 
 
You asked the Plan to pay for the special pump services. You say that this equipment was provided to the 
enrollee during an inpatient stay and should be covered. The Plan denied your request. The Plan says this claim 
cannot be paid separately based on Medicare guidelines for inpatient services. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers.  
 
This equipment was used during a surgical procedure by the facility while the enrollee was an inpatient. 
Payment for this service would have been included under the facility claim. Payment to you for this service is 
the responsibility of the facility or hospital. Based on this information, we decided that Medicare rules for 
coverage of special pump services have been met. Therefore, we decided that the Plan does not have to pay for 
assembly and operation of pump with oxygenator or heat exchanger provided on February 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laminectomy services coded 63047 and 63048 provided 
on November 8, 2019. 
 
You asked the Plan to pay for the laminectomy services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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, we have confirmed that codes 
63047 and 63048 for the laminectomy services have a bundled relationship with code 22633 and cannot be paid 
as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing 
criteria have not been met.  
 
 
 
Therefore, we decided that the Plan does not have to pay for the laminectomy services coded 63047 and 63048 
provided on November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 8, 2020. 
 
You asked the Plan to pay for the office visit. You say that this was denied due to the enrollee being in hospice 
but the benefits obtained from the plan do not show additional coverage on this service date. The Plan denied 
your request. The Plan says the enrollee had elected hospice on March 26, 2020. This information is available 
to the provider who is responsible to ensure the correct payer is billed. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the office visit provided on April 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management provided on November 
29, 2019. 
 
You asked the Plan to pay for hospital discharge day management. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the documentation submitted does not support a hospital discharge day management service of 
more than 30 minutes in duration. 
 
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 99239 is hospital discharge day management, more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the record does not show 
that this service was more than 30 minutes in duration. Based on this information, we decided that Medicare 
rules for coverage of hospital discharge day management have not been met. Therefore, we decided that the 
Plan does not have to pay for hospital discharge day management provided on November 29, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular genetic hereditary predictive screening testing 
provided on September 5, 2019. 
 
You asked the Plan to pay for the molecular genetic hereditary predictive screening testing. 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 a covered benefit. 
 
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 molecular genetic hereditary predictive screening testing at issue in this appeal was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the molecular genetic hereditary predictive screening testing provided on 
September 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needles (A4215) provided on February 3, 2020. 
 
You asked the Plan to pay for needles. You say that you should be paid at the in-network rate. The Plan denied 
your request. The Plan says payment for these items is included in the payment for the services they were used 
for. 
 
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 CPT code A4215 is not supported in the medical record. Specifically, this code as a status code of 
X and is statutorily excluded. Based on this information, we decided that Medicare rules for coverage of 
needles have not been met. Therefore, we decided that the Plan does not have to pay for needles (A4215) 
provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 18, 
2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges 
because no visit occurred. 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 $45 
copayment for each specialist visit.  
 
The medical records show that you received specialist services on February 18, 2020. Therefore, you are 
responsible to pay the $45 copayment.  
 
You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits 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 visit provided on February 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Gammaplex injection coded J1557, the infusion supplies 
coded A4222, and the supplies for maintenance of non-insulin drug infusion catheter coded A4221 provided on 
December 31, 2019. 
 
You asked the Plan to pay for the Gammaplex injection, the infusion supplies, and the supplies for maintenance 
of non-insulin drug infusion catheter. You say that you would like the plan to reconsider their denial. The Plan 
denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 documentation 
submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of 
delivery. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the Gammaplex injection coded J1557, 
the infusion supplies coded A4222, and the supplies for maintenance of non-insulin drug infusion catheter 
coded A4221 provided on December 31, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for laboratory testing provided on March 10, 
2020. 
 
You asked the Plan to waive the coinsurance for lab test. You say that you feel that you are being overcharged 
for this test. The Plan denied your request. The Plan says the coinsurance amount you are being charged is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for lab test. The allowed amount of the claim is $38.49, resulting in a coinsurance obligation of 
$7.70. 
 
You have been asked to pay 20% coinsurance for lab test. Lab test falls 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 coinsurance 
for laboratory testing provided on March 10, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 3, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services should be covered because they 
were medically necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not 
covered. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided 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 medical services provided on March 3, 2020 
by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 5, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you accidentally missed that you needed 
authorization for this service.  You are requesting this to be covered as a one-time courtesy. The Plan denied 
your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 medical services provided on February 5, 2020 
by an out of network (OON) provider.