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

 
We decided that the Plan does not have to pay for the ambulance services provided on May 29, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were having chest pain and your life 
alert system called the ambulance. 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 29, 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 29, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 8, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was ordered via telemedicine, which is a Medicare-prohibited action. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for laboratory services provided 
to the enrollee on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on May 7, 2020. 
 
You asked the Plan to pay for the eye refraction. You say that you did not think you needed to go to another 
provider after your cataract surgery. The Plan denied your request. The Plan says eye refractions must be 
obtained through the Plans vision care provider. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the provider at issue in this case is not a Plan 
vision care provider. Based on this information, we decided that the Plan's rules for coverage of the eye 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction 
provided on May 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on April 9, 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 codes 15004, 15002, and 15003 are 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 15004 is surgical preparation of recipient site of digit by 
excision of burn eschar, first 1% or less of body area of infants and children. The definition of code 15002 is 
surgical preparation of recipient site of arm by excision of burn eschar, first 1% of body area of infants and 
children. The definition of code 15003 is surgical preparation of recipient site of arm by excision of burn 
eschar, each additional 1% or less of body area of infants and children. 
 
We find that CPT codes 15004, 15002, and 15003 are not supported in the medical record. Specifically, there is 
no documentation of surgical preparation or creation of a recipient site to support codes 15002, 15003, and 
15004. 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 surgical services rendered on April 9, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 8, 
2020. 
 
You asked the Plan to pay for the limited oral evaluation (D0140). You say that it was medically necessary to 
have the exam again. You say that the Plan should cover it. The Plan denied your request. The Plan says the 
service exceeds the frequency limitation in benefit 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, you also have a maximum benefit of 
one limited oral exam per plan year. The Plan paid for a limited oral evaluation provided on May 14, 2020, 
which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided on June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical preparation or creation of recipient site by 
excision of open wounds, burn eschar, or scar services coded 15002 and 15003 provided on March 23, 2020. 
 
You asked the Plan to pay for the surgical preparation or creation of recipient site by excision of open wounds, 
burn eschar, or scar services. You say that you would like the plan to reconsider their denial. The Plan denied 
your request. The Plan says the services billed are not supported by the documentation. 
 
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 codes 15002 and 15003 are not supported in the medical record. Specifically, the operative 
report did not include documentation of a surgical preparation or creation of recipient site by excision of open 
wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, 
arms, legs; first 100 sq cm or 1% of body area of infants and children; therefore, code 15002 cannot be verified. 
Also, the operative report did not include documentation of a surgical preparation or creation of recipient site 
by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar 
contracture, trunk, arms, legs; each additional 100 sq cm, or part thereof, or each additional 1% of body area of 
infants and children (Listed separately in addition to code for primary procedure); therefore, code 15003 cannot 
be verified.  
 
Based on this information, we decided that Medicare rules for coverage of the surgical preparation or creation 
of recipient site by excision of open wounds, burn eschar, or scar services have not been met. Therefore, we 
decided that the Plan does not have to pay for the surgical preparation or creation of recipient site by excision 
of open wounds, burn eschar, or scar services coded 15002 and 15003 provided on March 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 molecular pathology genomic profiling 
provided to the enrollee on May 13, 2020. 
 
You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The 
Plan says Medicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic 
profiling for bladder cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the test have not been met. Therefore, we decided that the Plan does not have to pay for 
Guardant360 molecular pathology genomic profiling provided to the enrollee on May 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a haemophilus influenzae type b vaccine (90648), a 
poliovirus vaccine (90713), a tetanus, diphtheria toxoids and acellular pertussis vaccine (90715), and 
administration (90471, 90472) provided on February 17, 2020. 
 
You asked the Plan to pay for a haemophilus influenzae type b vaccine, a poliovirus vaccine, a tetanus, 
diphtheria toxoids and acellular pertussis vaccine, and administration. You say that these vaccines were 
medically necessary. The Plan denied your request. The Plan says these vaccines are the responsibility of the 
enrollee's prescription drug plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a haemophilus 
influenzae type b vaccine, a poliovirus vaccine, a tetanus, diphtheria toxoids and acellular pertussis vaccine, 
and administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to a haemophilus 
influenzae type b vaccine, a poliovirus vaccine, a tetanus, diphtheria toxoids and acellular pertussis vaccine, 
and administration. Therefore, we decided that the Plan does not have to pay for a haemophilus influenzae type 
b vaccine (90648), a poliovirus vaccine (90713), a tetanus, diphtheria toxoids and acellular pertussis vaccine 
(90715), and administration (90471, 90472) provided on February 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable x-ray services (71045, Q0092, R0070) services 
provided on September 13, 2019. 
 
You asked the Plan to pay for portable x-ray services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not pre-authorized or emergent. There were network 
providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the 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 portable x-ray services (71045, Q0092, R0070) services provided on 
September 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the respiratory assist device provided on 
May 12, 2020. 
 
You asked the Plan to waive the copayment for the respiratory assist device. You say that you should not be 
responsible for the full amount since you did not keep the device for the entire month. The Plan denied your 
request. The Plan says that you are responsible for the cost share amount 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 20% 
coinsurance for durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a 20% coinsurance for the respiratory assist device. The respiratory assist device 
falls within the durable medical equipment (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 copayment for the respiratory assist device provided on May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided from January 13, 2020 to 
March 9, 2020. 
 
You asked the Plan to pay for acupuncture. You say that these services are covered. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because acupuncture is only covered 
for chronic lower back pain and is excluded for the diagnoses billed on this claim. 
 
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.  
 
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 enrollee did not have a diagnosis of chronic lower 
back pain which is the only covered indication for acupuncture. Therefore, we decided that the Plan does not 
have to pay for acupuncture services provided from January 13, 2020 to March 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the outpatient surgical services rendered. 
 
You asked the Plan to waive the copayments for these services. You say that no one told you about the 
copayments. The Plan denied your request. The Plan says the copayments were 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 $175 
copayment for each Medicare-covered outpatient admission to an ambulatory surgical center or outpatient 
hospital facility.  
 
Review of the file shows that you received outpatient surgery services.  
You have been asked to pay a $175 copayment per date of service for these services, for a total of $350. These 
services fall within the Medicare-covered outpatient admission to an ambulatory surgical center or outpatient 
hospital facility 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 copayments for the outpatient surgical 
services rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nerve conduction studies (95911) and needle 
electromyography (95886) provided on February 10, 2020. 
 
You asked the Plan to pay for nerve conduction studies and needle electromyography. You say that these codes 
are documented. The Plan denied your request. The Plan says these codes are 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 95911is nerve conduction studies; 9-10 studies and 
95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with 
nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by 
three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). 
 
We find that CPT code 95911 and 95886 is not supported in the medical record. Specifically, the procedure 
note does not document these procedures being performed. Based on this information, we decided that 
Medicare rules for coverage of nerve conduction studies and needle electromyography have not been met. 
Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95911) and needle 
electromyography (95886) provided on February 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services rendered on July 6, 2019. 
 
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 70551 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 70551 is magnetic resonance (eg, proton) imaging, brain 
(including brain stem); without contrast material. 
 
We find that CPT code 70551 is not supported in the medical record. Specifically, there is no documentation 
that MRI of the brain was performed. 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 imaging 
services rendered on July 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
April 20, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a 
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary 
and conducted a face-to-face assessment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the durable medical equipment have not been met. Specifically, medical records do not support a 
prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an 
appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was 
performed. The information submitted does not confirm that Medicare coverage criteria have been met. 
 Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the 
enrollee on April 20, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on December 30, 2019. 
 
You asked the Plan to pay for subsequent hospital care. You say that hospice was revoked prior to this visit. 
You say that the claim should be reprocessed for payment. The Plan denied your request. The Plan says 
Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 25, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent hospital 
care provided on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services received on April 13, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program.  
 
The rendering provider is not eligible to bill Medicare. The Plan did not pre-approve the services. 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 dental services received on April 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 
17, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) codes 80053 (1 Unit), 85025 (1 Unit), 80061 (1 Unit) 
and 36415 (1 Unit) remain 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. 
 
We find that the various CPT codes are not supported in the medical record. Specifically, the place of service 
on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim 
reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a 
doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services 
provided to the enrollee on September 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on May 12, 2020. 
 
You asked the Plan to pay for the imaging services. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for imaging services provided on May 12, 2020.