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

 
We decided that the Plan does not have to pay for the acupuncture services provided by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the acupuncture services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered were not a covered benefit. 
 
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 acupuncture services provided by an out 
of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehabilitation for management of her conditions. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform 15 hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care such as skilled nursing facility or sub-acute rehabilitation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140) and the panoramic x-ray (D0330) provided on April 17, 2020.You asked the Plan to pay forthe dental service. You say that you went to another dental facility where you were told that the teeth can be repaired. You also say that you are unable to eat.The Plan denied your request. The Plan says limited oral evaluation is not considered a routine oral exam. The Plan says that the limited oral evaluation is not listed as a covered service. The Plan says that 1 panoramic x-ray is covered every 36 months. The Plan also says that the frequency limit for this service has been exhausted.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 limited oral evaluation is not among those covered under this benefit. Additionally, the frequency limit of 1 panoramic x-ray every 36 months has been exceeded. The record shows that the Plan paid for a panoramic x-ray that you received on January 30, 2019, less than 36 months ago.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140) and the panoramic x-ray (D0330) provided on April 17, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on April 13, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges 
because you were transferred to another facility due to COVID-19. 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 April 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe IV tubing extension kit (S1015) and infection control supplies (S8301) provided on July 20, 2020.You asked the Plan to pay forthe supplies. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT codes S1015 and S8301 have a status indicator of I and are 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 thatCPT code S1015 and S8301 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT codes S1015 and S8301 have a status indicator of I. This means that CPT codes S1015 and S8301 are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met.Therefore, we decided that the Plan does not have to pay forthe IV tubing extension kit (S1015) and infection control supplies (S8301) provided on July 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nplate 250 mcg subcutaneous solution (J2796). 
 
You asked the Plan to pre-approve Nplate. You say that Nplate is medically necessary. The Plan denied your 
request. The Plan says this drug is not covered for the enrollee's diagnosis. 
 
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 pre-approve Nplate. Our reviewer says that This 
drug is not medically necessary. Our physician reviewer found the requested treatment was ordered to improve 
platelet count. Review of the compendia shows Nplate is used in patients who have had an inadequate response 
to corticosteroids, immunoglobulins, or splenectomy.  Reviewed records do not support these treatments were 
trialed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nplate have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Nplate 250 mcg subcutaneous solution (J2796).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 18, 2020 by an out of 
network (OON) provider. 
 
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 services were rendered by an out-of-network provider without 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 medical services provided on June 18, 2020 by 
an out of network (OON) provider.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay fora transvaginal ultrasound (76830) provided on June 3, 2020.You asked the Plan to pay fora transvaginal ultrasound. You say that this should be covered.The Plan denied your request. The Plan says that the diagnosis does not support medical necessity.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 a transvaginal ultrasound. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the Plan states it is denying coverage because they don't accept diagnosis code R93.89 (abnormal findings on diagnostic imaging) as a reason for performing the transvaginal ultrasound. However, their list of specific indications covered states:  further characterization of pelvic abnormality detected by other diagnostic imaging.  Therefore, this pelvic ultrasound was indicated, medically reasonable and necessary, and should be covered. It is not uncommon that pelvic ultrasounds are performed to follow up on pelvic findings on CT scans.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a transvaginal ultrasound have been met.Therefore, we decided that the Plan has to pay fora transvaginal ultrasound (76830) provided on June 3, 2020.If thePlan 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. Thisdoes not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient stay provided from June 11, 
2020, through June 15, 2020. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that the doctor advised you to go to 
this hospital because it was an emergency. You say that the bill is too high. The Plan denied your request. The 
Plan says the copayment applied 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 $375 
copayment each day for days 1 to 5 for in-network, Medicare-covered hospital care. $0 copayment for 
additional Medicare-covered days.  
 
You have been asked to pay a $1,500 copayment for the inpatient stay. ($375/day x 4 days = $1,500). The 
inpatient stay falls within the "Inpatient Hospital Care" benefit category. The records show that the claim was 
processed in-network. 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 inpatient stay provided from 
June 11, 2020, through June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit provided on July 30, 2020. 
 
You asked the Plan to waive the deductible for the office visit. You say that you should not have a payment due 
to the provider. The Plan denied your request. The Plan says the amount went towards your annual deductible. 
 
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 $100 deductible.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $100 deductible. This cost 
sharing is a contractual obligation that had not been met at the time the office visit claim was received for 
services on July 30, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the 
office visit provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services rendered on January 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 procedure code 99239 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of 
more than 30 minutes of discharge services spent on the enrollee. 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 hospital discharge services rendered on January 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on July 30, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you cannot afford the bill. The Plan 
denied your request. The Plan says the copayment applied 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 $250 per 
day for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay a $250 copayment for the CT scan. The CT scan 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 the CT scan provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hyaluronan or derivative, euflexxa, for intra-articular 
injection services coded J7323 provided. 
 
You asked the Plan to pay for the Hyaluronan or derivative, euflexxa, for intra-articular injection services. You 
say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
amount of units billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code J7323 is 2. You billed 4 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the Hyaluronan or derivative, euflexxa, for 
intra-articular injection services have not been met. Therefore, we decided that the Plan does not have to pay 
for the Hyaluronan or derivative, euflexxa, for intra-articular injection services coded J7323 provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on August 27,
2020.
You asked the Plan to waive the copayment for the office visit. You say that there was no additional diagnosis
made to apply a copayment. The Plan denied your request. The Plan says the copayment applied 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 $10 for
each covered visit or consultation in an outpatient location with your PCP or other primary care provider.
You have been asked to pay a $10 copayment for the office visit. The office visit falls within the
"Physician/Practitioner services, including doctor's office visits" benefit category. The records show that your
diagnosis of fatty liver, diabetes and obesity were discussed, and diagnostic testing was ordered during the
office visit.
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 office visit provided on August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture (97810, 97811) provided on August 19, 2020. 
 
You asked the Plan to pay for acupuncture. You say that you were told this would be covered. The Plan denied 
your request. The Plan says this is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan?s rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the record does not show that the enrollee had a 
chronic pain diagnosis. Therefore, we decided that the Plan does not have to pay for acupuncture (97810, 
97811) provided on August 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic shoe inserts (A5501, A5513) provided. 
 
You asked the Plan to pay for diabetic shoe inserts. You say that these items were medically necessary. The 
Plan denied your request. The Plan says there is no 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. This documentation 
has not been submitted. 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 diabetic shoe 
inserts (A5501, A5513) provided.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home therapy services (S9342) provided on June 1, 2020, 
through June 30, 2020. 
 
You asked the Plan to pay for the home therapy services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT code S9324 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 S9342 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9324 has a status indicator of I. This means that CPT code S9324 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home therapy services have not 
been met. Therefore, we decided that the Plan does not have to pay for the home therapy services (S9342) 
provided on June 1, 2020, through June 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for BRCA1 (BRCA1, DNA repair associated), BRCA2 
(BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence 
analysis and full duplication/deletion analysis (ie, detection of large gene rearrangements) (CPT Code 81162) 
provided on March 27, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says Medicare says tests with no relation to a medical diagnosis of disease for the health of 
the patient are not a benefit. 
 
 
 
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 services, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast 
and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis (ie, detection of 
large gene rearrangements) (CPT Code 81162) provided on March 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a new patient office visit (99202) provided on August 24, 2020. 
 
You asked the Plan to pay for a new patient office visit. You say that the patient has not been seen for 
dermatology by this provider. The Plan denied your request. The Plan says the patient was not a new patient. 
 
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 99202 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires these 3 key components: An expanded problem focused 
history; An expanded problem focused examination; Straightforward medical decision making. Counseling 
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the 
presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the 
patient and/or family. 
 
We find that CPT code 99202 is not supported in the medical record. Specifically, the record shows that the 
enrollee previously received and evaluation and management service from this provider in July and is not a 
new patient. Based on this information, we decided that Medicare rules for coverage of a new patient office 
visit have not been met. Therefore, we decided that the Plan does not have to pay for a new patient office visit 
(99202) provided on August 24, 2020.