Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to hold you harmless for laboratory services. We decided that the Plan does not 
have to hold you harmless for breast biopsy surgery.  
 
You asked the Plan to hold you harmless for laboratory services. You say that these services should be 
considered one service. The Plan says that these services processed correctly. 
 
We decided that the Plan has to hold you harmless for laboratory services.  
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. The rules also say that Medicare health plans must make reasonable and diligent 
efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 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 enrollees must pay a 20% coinsurance for diagnostic procedures and tests 
provided in an outpatient hospital. 
 
You received these laboratory services from an in-network provider. The file does not show that the Plan 
provided notice that these laboratory services would not be covered. Under Medicare rules, this means these 
services are considered approved by the Plan. The record shows that you have been asked to pay the full charge 
of $18.10 listed on the Explanation of Benefits for laboratory services. The Plan has not submitted any 
information about how this cost-share was calculated, such as the total allowed amount. Therefore, we decided 
that the Plan has to hold you harmless for laboratory services.  
 
We also decided that the Plan does not have to hold you harmless for breast biopsy surgery. 
 
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 $250 
copayment for outpatient surgery. 
 
You have been asked to pay $250 for breast biopsy surgery. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to hold you harmless for 
breast biopsy surgery. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug screening provided on April 27, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the drug screening. You say that these were denied due to lack of authorization 
and retro authorization was refused. As such, the denial is appealed as payment should be made. The Plan 
denied your request. The Plan says there is no coverage under the plan for non-emergency out of network care 
provided without a 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 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 drug screening provided on April 27, 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 specialist services provided on January 2, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says there is no referral on file. The Plan says 
that since prior authorization was not obtained, these services have 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 specialist services provided on January 2, 2020 by 
an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided 
on April 24, 2020. 
 
You asked the Plan to waive the copayment for outpatient rehabilitation 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay $30, which is less than the $35 copayment for outpatient rehabilitation services. 
Outpatient rehabilitation services fall within the outpatient rehabilitation 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 rehabilitation services provided on April 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided during laparoscopy 
services on December 12, 2019. 
 
You asked the Plan to pay for the assistant surgeon services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services 
provided during laparoscopy services on December 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on March 7, 2020, 
and March 8, 2020. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says the 
enrollee's care could have been managed at a lower level. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that due to the objective testing suggesting no acute coronary syndrome 
present, and as vitals were stable, there was no clear indication for admission. There was no treatment or testing 
which would have warranted at least a two-midnight stay. Repeat troponin, vitals checking, and symptom 
management could have been managed via a lower level of care, in less time, based on the documentation. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided on March 7, 2020, and March 8, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two crowns and two core buildups, including any pins 
when required provided on March 2, 2020. 
 
You asked the Plan to pay for the crowns and core buildups. You say that this is the same office and dentist that 
you saw previously. The Plan denied your request. The Plan says these 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two 
crowns and two core buildups, including any pins when required provided on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 9, 2020 by an out-
of-network provider. 
 
You asked the Plan to pay for the medical services. You say that you verified over the phone that the claims 
denied because an authorization was required and the  Plan would not allow a retro auth. The Plan denied your 
request. The Plan says these visits to a non-contracted pain management clinic were not authorized and all 
services provided outside of the network must be pre-authorized. 
 
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 January 9, 2020 
by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on December 11, 2019. 
 
You asked the Plan to waive the coinsurance for DME. You say that you were told you would not owe 
anything for the 10 day rental. 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 20% 
coinsurance for DME and related supplies.  
 
You received DME on December 11, 2019. The allowed amount is $1,408 and 20% of that is $281.60.  
 
You have been asked to pay the total coinsurance amount of $281.60 for DME. DME falls within the DME and 
related supplies 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 DME provided on 
December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy (D3320) and extraction (D7210) 
provided on March 20, 2020. 
 
You asked the Plan to pay for the endodontic therapy and extraction. You say that the enrollee's dentist was 
closed due to the COVID-19 pandemic. The Plan denied your request. The Plan says these 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
endodontic therapy (D3320) and extraction (D7210) provided on March 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bronchoscopy (31624) and critical care (99292) provided 
on March 5, 2020. 
 
You asked the Plan to pay for the bronchoscopy and critical care. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does 
not support the service billed. 
 
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 31624 is bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with bronchial alveolar lavage. 
 
The CPT Code Manual definition of code 99292 is critical care, evaluation and management of the critically ill 
or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service). 
 
We asked our coder 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 bronchoscopy and critical care. Our reviewer says that 
CPT codes 31624 and 99292 do not meet criteria for billing or reimbursement consideration. Our reviewer 
found the critical care report documents "60 minutes of non-overlapping critical care time.  This does not 
include additional time spent on procedures".  Actual additional time was not documented, therefore, cannot be 
verified.  In addition, documentation did not include report for Bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with bronchial alveolar lavage.  Therefore this code cannot be verified 
as performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the bronchoscopy and critical care have not been met. Therefore, we decided 
that the Plan does not have to pay for the bronchoscopy (31624) and critical care (99292) provided on March 5, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on October 31, 2018. 
 
You asked the Plan to pay for the services. You say that the claim was not filed untimely. The Plan denied your 
request. The Plan says the claim was filed 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 provider billed the wrong insurance in 2018 and got a prompt denial of that claim on November 16, 2018. 
You still had until October 31, 2019 to find out the correct payer and submit the claim which you failed to do. 
The record shows that a claim for the services was not filed until after the one-year timeframe. 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 services provided on October 31, 2018.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the in-home/custodial care services provided March 11, 2020 
to March 18, 2020. 
 
You asked the Plan to pay for the in-home/custodial care services. You say that given the unique and 
unanticipated circumstances and following the recommendations of the treating provider, you are requesting a 
one-time administrative consideration. The Plan denied your request. The Plan says custodial care services are 
not covered by Medicare or the plan. 
 
The Plan must follow Medicare rules. The rules say that custodial care is not covered. Based on this 
information, we decided that Medicare rules for coverage of the in-home/custodial care services have not been 
met. Therefore, we decided that the Plan does not have to pay for the in-home/custodial care services provided 
March 11, 2020 to March 18, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest ultrasound (76604) provided on May 20, 2020. 
 
You asked the Plan to pay for the ultrasound. You say that you would like reconsideration because this service 
was billed correctly. The Plan denied your request. The Plan says this claim was submitted with a place of 
service that does not match the member's correct inpatient status. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician/practitioner/supplier furnishing 
services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 
21 irrespective of the setting where the patient actually receives the face-to-face encounter. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ultrasound have not been met. Specifically, the record indicates that this member was 
registered inpatient on the billed date of service. This claim was submitted with place of service code 22 for on 
campus-outpatient hospital. This is not an appropriate place of service code. Therefore, we decided that the 
Plan does not have to pay for a chest ultrasound (76604) provided on May 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on May 14, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges 
because this was a telehealth visit. 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 $45 
copayment for specialist services, including telehealth services.  
 
You have been asked to pay a $45 copayment for a specialist visit. A specialist 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 visit provided on May 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound examination of the heart 
(93306) on May 20, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound examination of the heart. You say that last year 
you paid $0 for this exact test. 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 $10 
copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility).  
 
You have been asked to pay a $10 copayment for an ultrasound examination of the heart. An ultrasound 
examination of the heart falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 
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 ultrasound examination of the 
heart (93306) on May 20, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the Aflibercept injection (67028, J0178) provided on November 8, 
2019. 
 
You asked the Plan to pay for the injection. The Plan denied your request. The Plan says that this is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the injection. Our reviewer says that the 
requested Aflibercept injection is medically reasonable and necessary. Our physician reviewer found that in 
clinical trials, Aflibercept has been shown to be effective in the treatment of exudative age-related macular 
degeneration, and is FDA-approved. 
 
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 injection have been met. Therefore, we decided that the Plan has to pay for 
the Aflibercept injection (67028, J0178) provided on November 8, 2019.  
 
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.