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

We decided that the Plan does not have to pay for tissue transfer (14060-59).

You asked the Plan to pay for tissue transfer. You say that this service is documented in the records. The Plan denied your request. The Plan says this is not supported in 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.

In this case, the CPT Code Manual definition of code 14060-59 is adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less. 

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 tissue transfer. Our reviewer says that the billing of this code is not supported. Our physician reviewer found the medical records provided do not include sufficient documentation to validate CPT 14060-59 was provided as per the coding definition of the procedure, therefore, this service cannot be verified.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tissue transfer have not been met. Therefore, we decided that the Plan does not have to pay for tissue transfer (14060-59).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for rehab services received from July 22, 2020 to November 2, 
2020. 
 
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 these codes are not valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that HCPCS codes H0001 and H2035 are not supported in the medical record. Specifically, these 
codes have a status indicator of "I" according to the Medicare Physician's Fee Schedule. This means that these 
codes are not valid for Medicare use. 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 rehab services 
received from July 22, 2020 to November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Periodontal maintenance (D4910) provided November 
24, 2020. 
 
You asked the Plan to pay for the Periodontal maintenance. You say that you should have been billed and 
covered as a regular dental cleaning. The Plan denied your request. The Plan says the service is not covered 
under your dental benefits. 
 
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 
Periodontal maintenance (D4910) provided November 24, 2020.  
 
Your complaint about how the service was billed is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 28, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 
physician's services. 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 October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on October 6, 2020. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you were never told that these 
injections would be this expensive. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $3,225.41. The total amount you are being asked to pay is $645.08 ($3,225.41 x 20% = $645.08). An 
injection falls 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 an injection provided by a participating provider on October 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish, periodontal 
maintenance, and four gingival irrigations provided on June 26, 2020. 
 
You asked the Plan to pay for the topical application of fluoride varnish, periodontal maintenance, and gingival 
irrigations. You say that you never received these services. The Plan denied your request. The Plan says these 
services are not covered. The Plan also says that they confirmed with this provider that you were at the office 
on this date, and these services were provided. 
 
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 
topical application of fluoride varnish, periodontal maintenance, and four gingival irrigations provided on June 
26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital admission you had 
on June 29, 2020. 
 
You asked the Plan to reduce the copayment for the inpatient hospital admission. You say that you were not 
admitted to the hospital so you should only have to pay the $125 outpatient copayment. 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 $300 
copayment per admission for inpatient hospital care.  
 
You have been asked to pay a $300 copayment per admission for the inpatient hospital admission. The medical 
records from this date of service clearly indicate that you were admitted as an inpatient for knee replacement 
surgery. 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 reduce the copayment for the inpatient hospital admission you had on 
June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hemodialysis procedures (90937) provided from October 4, 
2019, to November 22, 2019. 
 
You asked the Plan to pay for hemodialysis procedures. You say that this is a payable service. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare makes payment on the basis of ESRD 
procedure codes, i.e., codes 90935, 90937, 90945, or 90947, only if the place of service on the claim is 
inpatient hospital.  
 
We looked at the file and Medicare rules. These services were not billed with an inpatient hospital place of 
service on the claims. Based on this information, we decided that Medicare rules for coverage of hemodialysis 
procedures have not been met. Therefore, we decided that the Plan does not have to pay for hemodialysis 
procedures (90937) provided from October 4, 2019, to November 22, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric services provided on October 14, 2019 and brain 
imaging on October 15, 2019. 
 
You asked the Plan to pay for services (90889, 78607, 96146) provided on October 14, 2019 and October 15, 
2019. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the claim was 
untimely. 
 
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 claims for psychiatric services provided on October 14, 2019 and brain imaging on 
October 15, 2019 were not filed until October 15, 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 psychiatric services provided on October 14, 2019 and brain imaging on October 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on September 
5, 2019. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation (90971). You say that you did not receive 
proper notice of the enrollee's determination from the facility. The Plan denied your request. The Plan says the 
claim was untimely. 
 
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 psychiatric diagnostic evaluation (90971) was not filed until October 9, 
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 the psychiatric diagnostic evaluation 
provided on September 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), the cleaning (D1110), and the 
fluoride application (D1208) provided on July 21, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were never told that your dentist had parted 
ways from the plan. You say that were not aware of this until you received a bill. You say that is why this is 
passed the 60 day deadline. You also say that you did not know that you could appeal for a refund of what you 
paid out of pocket. The Plan denied your request. The Plan says the provider in this case has opted out of 
Medicare participation. The Plan also says that payment cannot be made for services that you receive from a 
provider who has opted out of Medicare participation. 
 
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 and the services are listed as covered, 
payment cannot be made for services that you receive from a provider who has opted out of Medicare 
participation. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), the cleaning 
(D1110), and the fluoride application (D1208) provided on July 21, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the individual therapy visits you had with 
a licensed clinical social worker from September 24, 2020, to December 3, 2020. 
 
You asked the Plan to waive the copayments for the therapy visits. You say that these visits were telehealth 
visits.  You also stated that you believe that these visits were billed as medical visits and not counseling visits, 
so that resulted in higher copayments being charged. The Plan denied your request. The Plan says you were 
charged these copayments 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 individual or group therapy visits.  
 
You have been asked to pay a $35 copayment for the therapy visits. The therapy visits fall within the individual 
or group therapy 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 copayments for the 
individual therapy visits you had with a licensed clinical social worker from September 24, 2020, to December 
3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on October 5, 2020. 
 
You asked the Plan to waive the coinsurance for an injection. You say that no one told you that it would cost 
this much. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $3,225.41. The total amount you are being asked to pay is $645.08 ($3,225.41 x 20% = $645.08). An 
injection falls 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 an injection provided by a participating provider on October 5, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for Tempus Gene Panel testing.

You asked the Plan to pay for the Tempus Gene Panel testing. You say that you would like reconsideration because this testing is useful for patients at initial diagnosis and patients with refractory disease. The Plan denied your request. The Plan says that this testing was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.

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 Tempus Gene Panel testing. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found molecular profiling is now considered a standard of care in patients with recurrent or persistent ovarian cancer. Primary peritoneal cancer is treated the same as ovarian cancer and this member meets this criteria.

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 Tempus Gene Panel testing have been met. Therefore, we decided that the Plan has to pay for Tempus Gene Panel testing.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided 
October 22, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you were dissatisfied with the 
services provided and do not feel you should be responsible for the cost. The Plan denied your request. The 
Plan says a comprehensive oral evaluation was previously covered which met your frequency limit. Therefore, 
the current service at issue is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the 
comprehensive oral evaluation once every 3 years.  
 
We looked at the file, and Medicare rules. The Plan provided evidence that already covered one comprehensive 
oral examination in February 2019. Based on this information, we decided that the Plan's rules for coverage of 
the comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay 
for the comprehensive oral evaluation (D0150) provided October 22, 2020.  
 
Your complaint about your office visit is not a valid appeal for medical coverage. This part of your complaint 
is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these 
types of complaints.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance services provided on May 4, 2020. 
 
You asked the Plan to pay for the air ambulance service. You say that you want to be paid for the air 
ambulance service at a ground ambulance allowance. The Plan denied your request. The Plan says this 
transport was non-emergent, and you did not request prior authorization. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance service. Our reviewer says 
that air or ground ambulance service was not medically necessary.  
Our physician reviewer found the document does not support the patient suffering from illness or injury that 
would contraindicate transportation by non-ambulance means. Based on the documentation, the patient's 
condition was not such that there was a time-dependent threat to survival or health. The patient did not meet the 
requirement for ground ambulance transport as medical expertise and equipment was not required to transport 
the patient. 
 
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 air ambulance service or ground ambulance service have not been met. 
Therefore, we decided that the Plan does not have to pay for air ambulance services provided on May 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on December 1, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider or 
a participating 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 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 outpatient services provided on December 1, 2020 
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery and vision care 
provided by a participating provider on January 23, 2020, to December 7, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery and vision care. You say that you do not 
feel like you should be responsible for these copayments. 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 $0-
$240 copayment for outpatient surgery and a $0-$35 copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $51.11 copayment for an outpatient surgery and a $35 copayment for each vision 
care visit. The amount you are being asked to pay for vision care services is $455 ($35 x 13 visits = $455). The 
total amount you are being asked to pay is $506.11 ($455 + $51.11 = $506.11). An outpatient surgery falls 
within the outpatient surgery benefit category and vision care falls within the physician/practitioner 
services/specialist benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgery 
and vision care provided by a participating provider on January 23, 2020, to December 7, 2020.