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

 
We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on 
October 29, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care services. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided 
were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 subsequent nursing facility care services 
provided on October 29, 2019, by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a gastrointestinal endoscopy (43239 and 
43249) performed on February 20, 2020. 
 
You asked the Plan to waive the copayment for a gastrointestinal endoscopy. You say that you were quoted a 
different copayment by a representative of the Plan. 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 $300 
copayment for each Medicare-covered ambulatory surgical center visit.  
 
You have been asked to pay a $300 copayment for a gastrointestinal endoscopy. A gastrointestinal endoscopy 
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 copayment for a gastrointestinal 
endoscopy (43239 and 43249) performed on February 20, 2020.  
 
Your complaint about receiving erroneous or misleading information from a representative of the Plan 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 18, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because the documentation does not 
support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. This claim was billed with Place of Service (POS) code 81 -
indicating an independent laboratory setting, however the documentation submitted does not support that the 
sample for this testing was obtained in an independent laboratory. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing provided on January 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chair lift. 
 
You asked the Plan to pre-approve the chair lift. You say that the chair lift is medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit, and it was provided by an out-of-network 
provider. 
 
The Plan covers all items that Medicare covers. Medicare rules state that chair lifts are not covered because 
they are not primarily medical in nature.  
 
While a chair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a chair lift.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility visit (99309) provided on 
October 1, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility visit. 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 subsequent nursing facility visit (99309) 
provided on October 1, 2019, by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on April 28, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the drugs provided are not a covered benefit. 
 
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 pay for the self-administered drugs 
provided on April 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for caregiver services provided from March 8, 2020, through 
March 21, 2020 by a non-Medicare provider. 
 
You asked the Plan to pay for the caregiver services. You say that the services should be covered as home 
wound care because the bandages were changed daily from March 8, 2020, through June 28, 2020. The Plan 
denied your request. The Plan says the services were not performed by a Medicare provider, nor is there a CPT 
code to indicate there were skilled services provided. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
caregiver services provided from March 8, 2020, through March 21, 2020 by a non-Medicare provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluation (90791) provided March 3, 
2020. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the rendering physician is a 
hospitalist physician with the group and depends on the hospital staff to verify eligibility and obtain proper 
authorization from the patients insurance company. The Plan denied your request. The Plan says with the 
information provided, it cannot be determined if a physician?s order was given, how the enrollee came to the 
servicing provider or whether the services are medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
In this case, medical records were needed from the provider to determine medical necessity and confirm that 
Medicare coverage criteria has been met. The records show that the plan had made multiple attempts to obtain 
the needed information from the provider and none was received. Non-contracted providers are required to 
furnish necessary information to the health plan when requested. Based on this information, we decided that 
Medicare rules for coverage of the psychiatric diagnostic evaluation have not been met. Therefore, we decided 
that the Plan does not have to pay for psychiatric diagnostic evaluation (90791) provided March 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation provided on October 1, 2019. 
 
You asked the Plan to pay for ambulance transport. You say that the automotive insurance has already 
processed this claim, so the Plan should process for payment. The Plan denied your request. The Plan says the 
denial of payment for this service is correct, because the Plan is the secondary payer for this claim and the 
primary payer has already paid more than the Medicare allowable amount for the services billed. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. If the primary payer does not pay in full for the services, 
Medicare secondary benefits may be paid. 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 received 
payment information from the primary payer and determined that the primary insurance carrier has already paid 
more than the Medicare allowable amount for this claim. Therefore, there is no remaining amount for the Plan 
to pay on this claim. Therefore, we decided that the Plan does not have to pay for ambulance transportation 
provided on October 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on May 5, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you were told that these 
copayments would be waived. The Plan denied your request. The Plan says the correct copayment has been 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $35 copayment for specialist services. The correct copayment has been applied 
to the services that were provided. Specialist services 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 specialist services provided by a 
participating provider on May 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forlab services provided on April 17, 2020.You asked the Plan to waive the deductible forlab services. You say that you disagree with the charges.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. Your contract with the Plan says that there is a $300 deductible for outpatient diagnostic tests and therapeutic services and supplies. You received lab services provided on April 17, 2020. The record shows that you had only paid $194.73 toward the $300 deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible balance of $105.27. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time lab services werereceived on April 17, 2020.Therefore, we decided that the Plan does not have to waive the deductible forlab services provided on April 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility visit (99308) provided on 
January 16, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility visit. 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 subsequent nursing facility visit (99308) 
provided on January 16, 2020, by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 18, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. 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 May 18, 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 provided on May 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography, neuromuscular junction 
testing, short-latency somatosensory evoked potential study, and the continuous intraoperative neurophysiology 
monitoring services provided on January 9, 2018. 
 
You asked the Plan to pay for the needle electromyography, neuromuscular junction testing, short-latency 
somatosensory evoked potential study, and the continuous intraoperative neurophysiology monitoring services. 
You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
services were submitted 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 needle electromyography, neuromuscular junction testing, short-latency 
somatosensory evoked potential study, and the continuous intraoperative neurophysiology monitoring services 
was not filed until May 19, 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 needle 
electromyography, neuromuscular junction testing, short-latency somatosensory evoked potential study, and 
the continuous intraoperative neurophysiology monitoring services provided on January 9, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray provided on June 2, 2020. 
 
You asked the Plan to pay for the panoramic x-ray. You say that you have never had this procedure done. The 
Plan denied your request. The Plan says the service is only covered once every 3 years. 
 
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, you also have a maximum benefit of 
one panoramic x-ray every three years. You received a panoramic x-ray on April 11, 2019, which exhausted 
your benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray provided on 
June 2, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on May 27, 2020. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you should not owe a copayment 
for a colonoscopy screening. 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 $200 
copayment for outpatient surgical procedures provided at an ambulatory surgical center.  
 
The medical records show that you had polyps removed during a colonoscopy on May 27, 2020. Therefore, the 
colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $200 copayment.  
 
You have been asked to pay a $200 copayment for a colonoscopy. A colonoscopy 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 copayment for a colonoscopy provided on May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transitional care management services provided on 
September 17, 2019. 
 
You asked the Plan to pay for the transitional care management 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, the CPT Code Manual definition of code 99495 is transitional Care Management Services with the 
following required elements: Communication (direct contact, telephone, electronic) with the patient and/or 
caregiver within 2 business days of discharge Medical decision making of at least moderate complexity during 
the service period face-to-face visit, within 14 calendar days of discharge. 
 
We find that CPT code 99495 is not supported in the medical record. Specifically, this service was billed with 
place of service of 31 (skilled nursing facility). This service was billed with an incorrect place of service. Based 
on this information, we decided that Medicare rules for coverage of the transitional care management services 
have not been met. Therefore, we decided that the Plan does not have to pay for the transitional care 
management services provided on September 17, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 7, 2019. 
 
You asked the Plan to pay for the laboratory services. 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare 
does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to 
pay for the laboratory services provided on December 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 19, 2020. 
 
You asked the Plan to pay for dental services. You say that this should be covered and applied toward your 
maximum out-of-pocket. The Plan denied your request. The Plan says payment cannot be issued for services 
performed by a provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
dental services provided on February 19, 2020.