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

 
We decided that the Plan does not have to waive the deductible for an X-ray provided on August 11, 2020. 
 
You asked the Plan to waive the deductible for an X-ray. You say that your X-ray report had nothing written 
about your condition and you feel that for this reason the service was not done due to your symptoms. 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 $750 deductible for outpatient diagnostic tests and therapeutic 
services and supplies.  
 
You received an X-ray on August 11, 2020. The record shows that you had paid $0 toward the $750 deductible 
prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $77.92.  
 
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 $750 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 an X-ray was 
received on August 11, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an 
X-ray provided on August 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (S9328) provided on July 2, 2020, 
through September 3, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because 
this service is not durable medical equipment and was not delivered to the member's home. The Plan denied 
your request. The Plan says CPT code S9328 has a status indicator of I which is 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 CPT code. 
 
We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9328) 
provided on July 2, 2020, through September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the removal of torus palatinus (D7472) and the 
removal of torus mandibularis (D7473ovided on August 4, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that you were in a lot of pain. You say 
that you had to borrow money to pay for the services. You also say that you are on a limited income. The Plan 
denied your request. The Plan says the removal of torus palatinus is not listed as a covered service. The Plan 
says that the removal of torus mandibularis is not listed as a covered service. The Plan also says that any 
services not listed are 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. 
 
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. The Evidence of Coverage clearly states that any services not listed are 
not covered requested items or services are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to reimburse you for the removal of torus palatinus (D7472) and the removal of 
torus mandibularis (D7473ovided on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on September 11, 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. The Plan says that the 
referring provider is also out-of-network. 
 
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 September 11, 
2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care services provided by a 
participating provider on July 25, 2020, to July 26, 2020. 
 
You asked the Plan to waive the copayment for emergency care services. You say that you were an inpatient. 
You say that you are being billed incorrectly. 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 $120 
copayment for emergency care/in-network/emergency services.  
 
You have been asked to pay a $120 copayment for emergency care services. Emergency care services fall 
within the emergency care/in-network/emergency 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 emergency care services provided by a participating provider on July 25, 2020, to 
July 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (G0481 and 80307) provided on June 29, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim was billed with the laboratory POS code but the records indicate the specimen was collected in an office.

The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, the record indicates that the specimen was collected in an office setting but the claim was billed with the laboratory POS code. Therefore, we decided that the Plan does not have to pay for the laboratory services (G0481 and 80307) provided on June 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdomen x-ray rendered on July 23, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that inpatient claims must be billed with POS code 
21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status on the date 
of service at issue and was incorrectly billed with POS code 22 for an outpatient hospital facility. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the abdomen x-ray rendered on July 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on August 13, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you said that it was the 
facilities decision to transport you so you should not be responsible for 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for ambulance services.  
 
You have been asked to pay a $225 copayment for ambulance services. Ambulance services fall within the 
ambulance 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 ambulance services 
provided on August 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four additional skilled nursing visits. 
 
You asked the Plan to pre-approve additional skilled nursing visits. You say that the enrollee needs additional 
skilled nursing visits. The Plan denied your request. The Plan says the additional skilled nursing visits are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional skilled nursing visits. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that skilled nursing services are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the patient's condition and/or prevent deterioration for the five unapproved 
visits. The provided medical records indicate that the enrollee's right lower extremity toe wound is closed with 
no other acute/unstable medical conditions reported indicating the need for additional nursing services. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional skilled nursing visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve four additional skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision services provided on February 13, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for vision 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. The Plan says that the member's 
primary care physician did not refer these 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 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 vision services provided on February 13, 2020 by 
an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray 
(D0220), the core build up (D2950), and the root canal (D3330) provided from July 8, 2020, to July 9, 2020. 
 
You asked the Plan to pay for the dental services. You say that your enrollment guide shows you have a limit 
of $2,500 towards dental services. You say that per the bill you received, the services should be covered 100%. 
The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that the 
services you received were paid at 100% of the maximum allowable charge. The Plan also says when you see 
an out of network provider, the provider can bill the difference between what was billed and what was paid by 
the plan. 
 
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, services that you receive out of 
network are paid up to the maximum allowable charge. Additionally, out of network providers can bill the 
difference between what was billed and what was paid by the plan. Therefore, we decided that the Plan does 
not have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220), the core build up (D2950), 
and the root canal (D3330) provided from July 8, 2020, to July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extractions (D7210) and drugs or medicaments 
(D9630) provided on August 31, 2020. 
 
You asked the Plan to pay more for the extractions (D7210) and drugs or medicaments (D9630). You say that 
the providers were approved before the services were provided. You say that the doctor should be paid at the 
in-network rate. The Plan denied your request. The Plan says the claim was processed correctly. 
 
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 Plan is only obligated to pay 50% 
of the allowed amount for the extractions. You are responsible for any amount greater than the MAC payment 
made by the plan to the provider. The drugs or medicaments (D9630) are not a covered benefit, therefore no 
payment was made by the Plan. Therefore, we decided that the Plan does not have to pay more for the 
extractions (D7210) and drugs or medicaments (D9630) provided on August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on July 7, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for the physician services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says you did not request 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 had network providers 
available who could have provided 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 physician services provided on July 7, 2020 by an out of network 
provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility services from 
January 22, 2021, forward. 
 
You asked the Plan to pre-approve additional skilled nursing facility services. You say that you believe if 
skilled services were to stop at this time the enrollee's level of function will start to decline. The Plan denied 
your request. The Plan says additional SNF services are not medically necessary. 
 
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 pre-approve additional skilled nursing facility 
services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is 
no documentation that the patient requires skilled nursing services, i.e., the specialized skill, knowledge and 
judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary 
and reasonable treatment beyond January 22, 2021. This patient does not require skilled therapy services, i.e., 
the specialized skill, knowledge and judgment of a qualified therapist is not required to safely and effectively 
provide medically necessary and reasonable treatment beyond January 22, 2021. This patient does not require 
the services on an inpatient basis, in a skilled nursing facility setting beyond January 22, 2021. Services in a 
long-term care facility on a part time basis or in the home with home health services appear appropriate 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 additional skilled nursing facility services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuation of skilled nursing facility services from 
January 22, 2021, forward.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the Emergency Dept. visit provided on 
September 13, 2020. 
 
You asked the Plan to waive the copayment for the Emergency Dept. visit. You say that the hospital 
overcharged for the service given. 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 $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for the Emergency Dept. visit. The Emergency Dept. 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 the 
Emergency Dept. visit provided on September 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology provided on August 5, 2020. 
 
You asked the Plan to pay for the molecular pathology. You say that you would like reconsideration because 
this service was medically necessary. The Plan denied your request. The Plan says Medicare denies coverage 
when a laboratory assays two or more genes in a patient in parallel. 
 
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 test at issue in this appeal, the molecular pathology, was requested solely for screening purposes. The 
documentation does not show that the requested pharmacogenomic testing was ordered due to any 
signs/symptoms of a drug reaction. There is no evidence that the testing was provided for therapeutic decision-
making regarding the need for the use of any specific drug. Therefore, we decided that the Plan does not have 
to pay for the molecular pathology provided on August 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for enteral feeding supplies (B4034, B4150) provided from 
August 30, 2019, to September 28, 2019. 
 
You asked the Plan to pay for enteral feeding supplies. You say that these items were medically necessary. The 
Plan denied your request. The Plan says there is not a proof of delivery for these items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The submitted 
documentation does not include a proof of delivery for the billed dates of service. 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 enteral feeding supplies (B4034, B4150) provided from August 30, 2019, to 
September 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9328) provided. 
 
You asked the Plan to pay for home infusion therapy. You say that this should be covered. The Plan denied 
your request. The Plan says this was not billed with a valid code. 
 
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 S9328 is not supported in the medical record. Specifically, this code has a status 
indicator. Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of home infusion therapy have not been met. 
Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided.