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

 
We decided that the Plan does not have to pay for the laboratory services provided on February 4, 2020, by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 laboratory services provided on February 4, 
2020, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided 
on May 22, 2020. 
 
You asked the Plan to pay for the CGP testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the CGP testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the Comprehensive Genomic Profile (CGP) testing provided on May 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a suspension sleeve (L2397). 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says there was valid physician order to verify the services billed. 
 
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 to support medical necessity for the supplies provided in 
this case. There is no itemized billing/shipping invoice to verify the services billed. 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 a suspension sleeve (L2397).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided October 
5, 2019, to October 19, 2019. 
 
You asked the Plan to pay for the SNF services. You say that the medical records provided will show proof of 
medical necessity. The Plan denied your request. The Plan says the Medicare criteria for continues SNF level 
of coverage were not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily 
basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided October 5, 2019, to October 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 73501 and 72170 provided on 
March 17, 2020. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 
73501 and 72170 for the x-ray services have a bundled relationship with code 73502 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 x-ray services coded 73501 
and 72170 provided on March 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Computed Tomography (CT) of the 
abdomen and pelvis (74176). 
 
You asked the Plan to waive the copayment for the CT scan. You say that the copayment should be waived as 
you were told by telephone that the copayment would only be $30. 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 $50 
copayment for CT scans in a freestanding clinic.  
 
You have been asked to pay a $50 copayment for a CT scan performed in a freestanding clinic. 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 Computed Tomography (CT) of the abdomen and pelvis (74176).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 12, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. 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 the testing was not ordered by an in-network provider. 
 
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 12, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for therapeutic, prophylactic, and diagnostic 
injections (96374) provided June 4, 2020. 
 
You asked the Plan to waive the coinsurance for the injection services. You say that you have the same 
treatment every 6 months and have not been charged in the past. The Plan denied your request. The Plan says 
the claim was reprocessed to remove the deductible charge and the correct coinsurance for Medicare Part B 
injection 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 20% 
coinsurance for Medicare part B injections for Medicare Part B prescription drugs.  
 
You have been asked to pay $30.91 ($154.59 x 20% = $30.91) for the injection services. The injection services 
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 therapeutic, prophylactic, and diagnostic injections (96374) provided June 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on June 1, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on June 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
May 20, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy for the enrollee's condition. The Plan denied your request. 
The Plan says the denial of payment for this testing is correct, because this testing was not billed with the 
appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service May 20, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on May 
20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital facility services. 
 
You asked the Plan to waive the copayment for outpatient hospital facility services. You say that you were only 
told, by your physician, about the outpatient surgery service copayment. The Plan denied your request. The 
Plan says you were charged the facility 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 $350 
copayment for outpatient hospital facility services.  
 
You have been asked to pay a $350 copayment for outpatient hospital facility services. Outpatient hospital 
facility services fall within the outpatient hospital services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for outpatient hospital facility services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-ray (D0220), the limited oral evaluation 
(D0140) and the office visit for observation (D9430) provided from August 29, 2019, to September 19, 2019. 
 
You asked the Plan to pay for the dental services. You say that the services you received were not routine 
dental services. You say that the services were needed to evaluate, treat and stabilize a medical condition 
resulting from a fall. The Plan denied your request. The Plan says the services you received are dental in 
nature. The Plan also says that Medicare does not cover routine dental services. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the periapical x-ray (D0220), the 
limited oral evaluation (D0140) and the office visit for observation (D9430) provided from August 29, 2019, to 
September 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation (A0428, A0425) provided October 
14, 2019. 
 
You asked the Plan to pay for the ambulance transport. You say that the transport was medically necessary. 
The Plan denied your request. The Plan says coverage criteria was not met. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance transport. Our reviewer says 
that ambulance transport was not medically necessary. Our physician reviewer found the enrollee's condition 
did not prevent transportation by other means such as a wheelchair van. There is no documentation that the 
patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped 
ambulance has. 
 
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 ambulance transport have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance transportation (A0428, A0425) provided October 14, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the bitewing x-rays provided on June 17, 2020. 
 
You asked the Plan to pay for the bitewing x-rays. You say that you did not realize you were one day short of 
the time frame for payment. The Plan denied your request. The Plan says that you were not eligible for 
additional bitewing x-rays. 
 
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.  
 
We looked at the Evidence of Coverage and case file. Based on this information, we decided that the Plan's 
rules for coverage of the bitewing x-rays have been met. The Plan contract does not clearly say that these x-
rays are limited to once every 12 months to the day. You would not be reasonably aware that the x-rays would 
be denied if provided one day prior than the previous year. Therefore, we decided that the Plan has to pay for 
the bitewing x-rays provided on June 17, 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 ultrasound (97035) and mechanical traction (97012) 
provided May 27, 2020. 
 
You asked the Plan to pay for the ultrasound and mechanical traction. You say that your chiropractor has done 
wonders for your back, which no other doctor could do. The traction table is a wonderful piece of equipment 
and you are appealing to pay for the therapy treatments. The Plan denied your request. The Plan says these 
services are not covered under the plan benefits. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the ultrasound (97035) and mechanical traction (97012) provided May 27, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a PICC line insertion (36573) provided May 1, 2020. 
 
You asked the Plan to pay for the PICC line insertion. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the claim is a duplicate. 
 
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 36573 is not supported in the medical record. Specifically, the record shows a claim 
was already processed for this service with a different place of service on the same date. The claim at issue is a 
duplicate and does not include a modifier to denote a separate and distinct service. Based on this information, 
we decided that Medicare rules for coverage of the PICC line insertion have not been met. Therefore, we 
decided that the Plan does not have to pay for a PICC line insertion (36573) provided May 1, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdomen x-ray provided on October 28, 2019. 
 
You asked the Plan to pay for the abdomen x-ray. You say that you would like the claim paid at the contracted 
rate. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all 
Medicare covered services related or unrelated to the enrollee's terminal condition. 
 
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 abdomen x-ray provided on October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services. 
 
You asked the Plan to pay for the psychotherapy 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 
psychotherapy 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 psychotherapy services.
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 services. The Plan denied your request. The Plan says the payment by the 
primary insurer exceeds what would have been paid by the Plan. 
 
The Plan must follow Medicare rules. The rules state that Medicare health plans are considered secondary 
insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying 
for services until the claim for those services has gone to the primary insurer. However, plans are still required 
to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary 
insurers in three ways. First, the plan can send the bill directly to the primary insurer for payment. Second, the 
plan can direct the provider to send the bill to the primary insurer. Third, the plan can pay for the services and 
submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has determined 
that the primary insurer has paid up to the limits of its coverage and the charges that remain are deductibles and 
coinsurance charges. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services (99283, 85024, 
80053, 36415) provided April 28, 2020. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that the copayment 
should be waived. 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 $120 
copayment for Emergency Care.  
 
You have been asked to pay a $120 copayment for the emergency room services. The emergency room services 
fall 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 
emergency room services (99283, 85024, 80053, 36415) provided April 28, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from March 3, 2020 to March 31, 2020.You asked the Plan to pay forhome health services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the required Q code, FIPS, CBSA and values were not billed on the claim submitted for payment.ThePlan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim submitted is missing a required Q code, FIPS, CBSA and values.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from March 3, 2020 to March 31, 2020.