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

We decided that the Plan does not have to pay for the emergency department visit (99283) provided August 24, 
2018. 
 
You asked the Plan to pay for the emergency visit. You say that you went to the emergency room due to a 
motor vehicle accident earlier that day. You are requesting the plan pay this bill in full. The Plan denied your 
request. The Plan says this claim was submitted past the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency visit was not filed until October 14, 2020. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the emergency department visit (99283) provided August 24, 
2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for arthrocentesis (20611) 
 
You asked the Plan to pay for arthrocentesis. You say that this code is supported. The Plan denied your request. 
The Plan says there is not sufficient documentation to support this 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. 
 
In this case, the CPT Code Manual definition of code 20611 is arthrocentesis, aspiration and/or injection, major 
joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording 
and reporting. 
 
We find that CPT code 20611 is not supported in the medical record. Specifically, this code requires permanent 
recording and reporting that is not included in the submitted documentation. Based on this information, we 
decided that Medicare rules for coverage of arthrocentesis have not been met. Therefore, we decided that the 
Plan does not have to pay for arthrocentesis (20611)
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT of the thorax and CT of the abdomen and pelvis 
provided on June 14, 2020. 
 
You asked the Plan to pay for the CT of the thorax and CT of the abdomen and pelvis. You say that these 
services were medically necessary. The Plan denied your request. The Plan says Original Medicare would be 
responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal 
condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the CT of the thorax and CT of the abdomen and pelvis 
provided on June 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance transportation provided on 
November 19, 2020. 
 
You asked the Plan to pay for ambulance transport. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of payment for this service is correct. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance transport. Our reviewer says that 
this transportation does not meet the Medicare criteria for payment. Our physician reviewer found the 
documentation does not show any evidence of contraindication to transportation by means other than 
ambulance (such as a stretcher van). The enrollee was stable and did not require the expertise or special 
equipment for non-emergent transportation to an appointment. The documentation does not support that this 
transportation was medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance transport have not been met. Therefore, we decided that the Plan 
does not have to pay for non-emergent ambulance transportation provided on November 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar/sacral orthosis provided to the enrollee on 
September 18, 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 according to the claims data available at the time of the review, the plan was unable to discover 
any evidence of an established relationship between the enrollee and ordering physician. 
 
The Plan must follow Medicare rules. The rules say a Standard Written Order (SWO) must be communicated 
to the supplier before a claim is submitted by the treating practitioner. 
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider/treating practitioner. Without a record showing that this provider is treating the enrollee, the criteria 
for coverage of these services has not been met. Therefore, we decided that the Plan does not have to pay for a 
lumbar/sacral orthosis provided to the enrollee on September 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99232) provided on October 19, 
2020. 
 
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says CPT code 99232 is a column II code to 
CPT code 99233 which was billed on the same date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that physicians in the same group practice who are in the same specialty must bill and be paid as 
though they were a single physician. 
 
We find that CPT code 99232 is not supported in the record. Specifically, the record indicates that an 
evaluation and management code for a physician with the same specialty was previously processed and paid for 
the same member and date of service. Based on this information, we decided that Medicare rules for coverage 
of the subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for 
subsequent hospital care (99232) provided on October 19, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EGD provided on August 26, 2020. 
 
You asked the Plan to waive the copayment for the EGD. You say that you are appealing this copayment. The 
Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for Medicare-covered surgery at an outpatient hospital facility.  
 
You have been asked to pay a $200 copayment for the EGD. The EGD falls within the Outpatient hospital 
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 the EGD provided on 
August 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composites (fillings) (D2330, D2392) 
provided on October 26, 2020. 
 
You asked the Plan to pay for the fillings. You say that you cannot afford this bill and do not understand why 
part of it was paid and part of it was denied. The Plan denied your request. The Plan says you have coverage 
for two restoration (filling) procedures per year. You received five, so while the first two were covered, the 
remaining three cannot be paid for because the benefit limit is 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, any fillings provided beyond the 
maximum of two per year are not covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the resin-based composites (fillings) (D2330, D2392) provided on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for injections and x-rays (J7326, 20610, 73562).

You asked the Plan to waive the copayment for the injections and x-rays. You say that the copayment should be waived because the cost of surgery would exceed the cost of the injections. The Plan denied your request. The Plan says the correct amount 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 20% coinsurance for Part B drugs and a $10 copayment for X-rays. 

You have been asked to pay a 20% coinsurance for the injections, which are considered Part B drugs, and a $10 copayment for the X-ray. 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 injections and x-rays (J7326, 20610, 73562).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumococcal conjugate vaccine.

You asked the Plan to pay for the pneumococcal conjugate vaccine. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 pneumococcal conjugate vaccine. 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 a pneumococcal conjugate vaccine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3330), core buildup (D2950), gingivectomy or gingivoplasty (D4212), retainer crowns (D6740), and ceramic/porcelain pontic (D6245).

You asked the Plan to pay for the dental services. You say that you cannot afford these services, and you were told that they would be covered by your Plan. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental benefit. In addition, the Plan indicated that they have reviewed the call logs in response to your concern and found that the provider was not told that the billed services were 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. Therefore, we decided that the Plan does not have to pay for the endodontic therapy (D3330), core buildup (D2950), gingivectomy or gingivoplasty (D4212), retainer crowns (D6740), and ceramic/porcelain pontic (D6245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on 
October 13, 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 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 a lumbar-sacral orthosis 
(L0648) provided to the enrollee on October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the oncology gene expression testing coded 0012M provided 
on September 25, 2020. 
 
You asked the Plan to pay for the oncology gene expression testing. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested 
 
The Plan must follow Medicare rules. Medicare rules say that CxBladder testing identified with code 0012M is 
non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oncology gene expression testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the oncology gene expression testing coded 0012M provided on September 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 8, 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. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on May 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lenses provided on September 3, 2020. 
 
You asked the Plan to pay for the progressive lenses. You say that you had cataract surgery so the eyeglasses 
should be covered. The Plan denied your request. The Plan says they will cover the frames with a 20% 
copayment but not the upgraded lenses. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of eyeglasses with standard frames and lenses. 
 
We looked at the file and the Plan's rules. Upgrades are not covered including progressive lenses Based on this 
information, we decided that the Plan's rules for coverage of the lenses have not been met. Therefore, we 
decided that the Plan does not have to pay for the progressive lenses provided on September 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder Detect testing coded 0012M.

You asked the Plan to pay for the Cxbladder Detect testing. 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 covered.

The Plan must follow Medicare rules. Medicare rules say that testing for CxBladder identified with code 0012M is non-covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Cxbladder Detect testing have not been met. Therefore, we decided that the Plan does not have to pay for the Cxbladder Detect testing coded 0012M.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the EKG and treatment of swallowing dysfunction.

You asked the Plan to waive the copayments for the ECG and the treatment of swallowing dysfunction. You say that you went to the doctor for a flu shot and now being billed $31.00 as your copayment. You say no other services were done. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount. However, if the provider is billing you for less than the actual cost share amount, then that is a matter between you and the provider.

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 $15 copayment for Medicare-covered non-radiological diagnostic services and a $40 copayment for each Medicare-covered physical therapy and speech-language therapy visit. 

You have been asked to pay a $15 copayment for the ECG and a $40 copayment for the treatment of swallowing dysfunction. The ECG falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The treatment of swallowing dysfunction falls within the "Outpatient Rehabilitation Services" benefit category. The medical record shows and ECG and Oropharyngeal dysphagia management services were performed.

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 ECG and treatment of swallowing disfunction.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone density study.

You asked the Plan to pay for the bone density study (77080). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the claim was untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the bone density study (77080) was not filed until October 30, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the bone density study.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician services provided by 
participating providers on May 9, 2020, to November 20, 2020. 
 
You asked the Plan to waive the copayment for physician services. You say that all cost-share amounts for the 
treatment of Covid-19 should be waived. The Plan denied your request. The Plan says testing services only 
related to Covid-19 when ordered by a provider are the only copayments that are being waived. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay the correct cost sharing amount for the services that were provided.  
 
The enrollee has been asked to pay the correct cost sharing amount for physician services. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for physician services provided by participating providers on May 9, 
2020, to November 20, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the Influenza vaccine and administration of the Influenza vaccine.

You asked the Plan to pay for the Influenza vaccine and administration. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the Influenza vaccine and administration of the Influenza vaccine
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on October 23, 
2020. 
 
You asked the Plan to pay for psychotherapy services. You say that this was billed correctly. The Plan denied 
your request. The Plan says this was billed with an incorrect POS. 
 
The Plan must follow Medicare rules. Medicare rules say that POS code 31 should be used with services for 
patients in a Part A covered skilled nursing facility stay and POS code 32 should be used with services for 
beneficiaries in a noncovered stay. 
 
We looked at the file and Medicare rules. The service at issue was billed with POS 31, but the record indicates 
that the enrollee was not in a covered SNF stay. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have not been met. Therefore, we decided that the Plan does not have to 
pay for psychotherapy services (90832) provided on October 23, 2020.