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

We decided that the Plan does not have to waive the copayment for a specialist office visit (99204) on August 
15, 2019. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you never had an 
outpatient visit on August 15, 2019. The Plan denied your request. The Plan says the correct copayment 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 a $40 
copayment for consultation, diagnosis, and treatment by a specialist.  
 
You have been asked to pay a $40 copayment for a specialist office visit. A specialist office 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 office visit (99204) on August 15, 2019.  
 
Your complaint that the services rendered to you on August 15, 2019, have been miscoded or misclassified 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI and an emergency room visit on 
February 26, 2020 and March 20, 2020. 
 
You asked the Plan to waive the copayment for an MRI and an emergency room visit. You say that you did not 
know that the hospital you visited was out-of-network. The Plan denied your request. The Plan says the 
copayment 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 a $100 
copayment for diagnostic radiology other than CT scans and a $90 copayment for emergency care.  
 
You have been asked to pay a $100 copayment and a $90 copayment for an MRI and an emergency room visit. 
MRIs fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. An 
emergency room visit falls within the emergency 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 an MRI and an emergency room visit on February 26, 2020 and March 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 11, 2020 billed 
with two units of code 36713 and two units of 34812. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary and 
coded correctly. The Plan denied your request. The Plan says these two codes have an MUE of 1 with MAI of 2 
meaning that more than one unit of service of these codes is never payable on the same date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT codes 34713 and 34812 is 1 with an MAI of 2. You billed two units of each of 
these codes, along with modifiers, exceeding the MUE. There is no exception allowed for MUEs with an MAI 
of 2. Based on this information, we decided that Medicare rules for coverage of the medical services have not 
been met. Therefore, we decided that the Plan does not have to pay for the medical services provided on 
February 11, 2020 billed with two units of code 36713 and two units of 34812.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from April 19, 2020 
to May 2, 2020. 
 
You asked the Plan to pay for the inpatient care. You say that you believe that this should be paid. The Plan 
denied your request. The Plan says the field for POA indicator was left blank for all diagnoses reported on the 
claim. This is not correct coding and the claim correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that all acute care hospital admissions must document 
the POA indicator for claims for services. Using an indicator of "1" or leaving the field blank is only 
appropriate for codes on the POA exempt list. 
 
In this case, all codes, which include codes not on the POA exempt list, had no POA indicator reported. A 
claim without an appropriate POA code is not payable as the proper DRG cannot be determined. Therefore, we 
decided that the Plan does not have to pay for the inpatient hospital services provided from April 19, 2020 to 
May 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services, initial 15 minutes of intraservice 
time, patient age 5 years or older (CPT Code 99152) provided on February 20, 2020. 
 
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 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. 
 
Current Procedural Terminology (CPT) code 99152 (1 Unit) remains not supported. CPT 99152represents 
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; initial 15 minutes of intraservice time, patient age 5 years or older. 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. Of 
note, an independent trained observer is someone other than the physician performing the services. It is noted 
that multiple attempts were made to contact the provider for additional information. 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, initial 15 minutes of intraservice time, patient age 5 
years or older (CPT Code 99152) provided on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 3, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that the provider is contracted. The Plan denied 
your request. The Plan says you do not have out-of-network benefits. 
 
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 3, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the discharge management services provided on May 27, 
2019. 
 
You asked the Plan to pay for the discharge management services. You say that the records support payment 
for the billed services. The Plan denied your request. The Plan says the discharge summary did not document 
that more than 30 minutes were spent providing this service. 
 
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 amount of time spent 
providing this service is not documented. Based on this information, we decided that Medicare rules for 
coverage of the discharge management services have not been met. Therefore, we decided that the Plan does 
not have to pay for the discharge management services provided on May 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ankle foot orthosis (L1971), plastic foot (L3170), knee 
orthosis (L1851), wrist hand orthosis (L3916), shoulder orthosis (L3960) and addition (L2397) provided on 
March 25, 2020. 
 
You asked the Plan to pay for the orthoses. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation submitted did not include an 
itemized shipping/billing invoice to indicate the specific supplies or proof of delivery 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. Specifically, the 
delivery ticket date does not match the billed date of service and the record does not include an itemized 
invoice. 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 ankle foot orthosis (L1971), plastic foot 
(L3170), knee orthosis (L1851), wrist hand orthosis (L3916), shoulder orthosis (L3960) and addition (L2397) 
provided on March 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bronchial thermoplasty (31661, 31660). 
 
You asked the Plan to pre-approve bronchial thermoplasty. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bronchial thermoplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bronchial thermoplasty is a treatment to be considered for patients with very severe 
asthma who continue to be symptomatic despite maximal medical treatment including steroids, long-acting 
beta agonists (LABAs), long-acting muscarinic agents (LAMAs), leukotriene antagonists, and biologics. The 
documentation does not support that the enrollee has very severe asthma with continued symptoms despite 
maximal medical treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bronchial thermoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bronchial thermoplasty (31661, 31660).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 31, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services were not authorized, the services are not considered urgent/emergent 
in nature. The Plan states there are multiple in-network providers within thirty (30) miles of the the member's 
residence that could have rendered the 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 the medical services provided on March 31, 2020 
by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 19, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you do not have the opportunity to 
preauthorize the services. The Plan denied your request. The Plan says the referring provider, the rendering 
provider, and the facility are all non-participating providers as well as no prior authorization or referral are 
found for the member; including no supporting documentation advising the services were urgent/emergent. 
 
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 19, 
2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Imbruvica 420mg tablet. 
 
You asked the Plan to pre-approve Imbruvica 420mg tablet. You say that the medication is necessary. The Plan 
denied your request. The Plan says the enrollee has a medical only policy which does not include Part D 
prescription coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Imbruvica 420mg tablet.  
 
Benefits for Imbruvica 420mg tablet may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration (20939). 
 
You asked the Plan to pre-approve bone marrow aspiration. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bone marrow aspiration. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspiration remains experimental in cases of spinal fusion surgery. More 
research is needed to show safety and efficacy. It is not the gold standard and not better than autogenous bone 
graft. It is not needed in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspiration (20939).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services 
 
You asked the Plan to pay for the ambulance services. You say that a neighbor called the ambulance for your 
husband. You also say that he didn't need to be transported to a hospital. The Plan denied your request. The 
Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 21, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the microbial DNA/RNA by PCR testing provided on May 8, 
2020. 
 
You asked the Plan to pay for the microbial DNA/RNA testing. You say that this testing should be covered due 
to medical necessity. The Plan denied your request. The Plan says the clinical value of this type of testing over 
standard testing methods is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 microbial DNA/RNA testing. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee tested positive for urinary tract infection. There is no evidence that a 
urine culture was obtained. he clinical value of PCR testing in the setting of urinary tract infections remains 
unproven in the peer-reviewed medical literature. The review has determined that the microbial DNA by PCR 
testing provided on 5/8/2020 was not medically necessary or reasonable. 
 
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 microbial DNA/RNA testing have not been met. Therefore, we decided that 
the Plan does not have to pay for the microbial DNA/RNA by PCR testing provided on May 8, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (G0463) provided on 
January 3, 2020. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the service were medically 
necessary. The Plan denied your request. The Plan says the services were not pre-authorized or emergent. 
There were network providers available. 
 
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 service 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 outpatient mental health services (G0463) provided on January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a naturopath office visit (99213) on 
February 6, 2020. 
 
You asked the Plan to waive the copayment for a naturopath office visit. You say that the naturopath you 
visited is your primary care provider (PCP) and you should be charged the PCP copayment. The Plan denied 
your request. The Plan says the correct copayment 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 defines a primary care provider 
(PCP) as a physician (MD or DO), physician's assistant (PA), or nurse practitioner (NP). Your contract with the 
Plan also clearly says that you must pay a $20 copayment for naturopathy services.  
 
You have been asked to pay a $20 copayment for a naturopath office visit. A naturopath office visit falls within 
the "Naturopathy" 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 naturopath office 
visit (99213) on February 6, 2020.  
 
Your complaint about the Plan not clearly answering your questions about the scope of naturopathy services 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental services provided on May 6, 2020. 
 
You asked the Plan to pay for dental services. You say that you went to the appointment, gave them your card 
and they started treatment. You say that you paid the amount they requested. The Plan denied your request. The 
Plan says out-of-network dental services are not covered 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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
services provided on May 6, 2020.