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

 
We decided that the Plan does not have to adjust the coinsurance for the electrophysiology evaluation (93620) 
provided on October 24, 2019. 
 
You asked the Plan to adjust the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the service provided. 
 
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 in-network diagnostic procedures and tests provided at an outpatient hospital.  
 
You have been asked to pay $964.98 ($4,824.90 Plan allowed amount x 20% coinsurance) for the in-network 
diagnostic test provided. 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 adjust the coinsurance for the electrophysiology 
evaluation (93620) provided on October 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you 
had on June 5, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that when you enrolled in the plan, you 
were told that CT scans had a $95 copayment.  You say that you cannot afford this copayment due to COVID-
19. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that 
there are no phone records showing you were told that a $95 copayment applies. 
 
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 diagnostic and nuclear medicine radiological services.  
 
You have been asked to pay a $225 copayment for the CT scan. The CT scan falls within the diagnostic and 
nuclear medicine radiological 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 computed tomography (CT) scan you had on June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing, gingival irrigation and 
unspecified preventive procedure provided on June 3, 2020. 
 
You asked the Plan to pay for periodontal scaling and root planing, gingival irrigation and unspecified 
preventive procedure. You say that you were referred by an in-network dental office, so you didn't know the 
provider was out-of-network. The Plan denied your request. The Plan says the 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 
periodontal scaling and root planing, gingival irrigation and unspecified preventive procedure provided on June 
3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay on November 2 to 
November 7, 2019. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this charge should be 
reconsidered. 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 $300 
copayment for each day of days 1-5 of each Medicare-covered inpatient hospital stay.  
 
You have been asked to pay 1,497.62, or less than a $300 copayment for each day of days 1-5, for an inpatient 
hospital stay. An inpatient hospital stay falls within the "Inpatient hospital care" benefit category. This means 
that you have been asked to pay less than the full 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 inpatient hospital stay on November 2 to November 7, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for actigraphy (95803) provided to the enrollee on December 3, 
2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says actigraphy can be measured as part of a sleep test but will not be paid for separately. 
Actigraphy is a non-covered service when it is not done as part of a sleep test or when it is used for monitoring. 
 
The Plan must follow Medicare rules. Medicare rules say that Actigraphy is a non-covered service when it is 
not done as part of a sleep test or when it is used for monitoring and cannot be billed as a separate service. 
Based on the claim submitted and the Medicare rules, criteria for coverage of this service are not met.  
Therefore, we decided that the Plan does not have to pay for actigraphy (95803) provided to the enrollee on 
December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from May 24, 
2020, to June 3, 2020.  
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says services rendered by non-Medicare eligible providers are not covered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
home health services provided to the enrollee from May 24, 2020, to June 3, 2020 provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99215) 
provided on December 19, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. You say that you would 
like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior 
authorization was not obtained by the facility or the provider; therefore, payment has 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 the established patient office or other outpatient 
visit (99215) provided on December 19, 2019, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient assisted living visit (99334) provided 
on April 30, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient assisted living visit. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization 
was not obtained by the facility or the provider; therefore, payment has 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 the established patient assisted living visit (99334) 
provided on April 30, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran aspiration or injection of large joint (20610) performed on March 12, 2020.You asked the Plan to waive the copayment foran aspiration or injection of large joint. You say that you have received this service before and paid a much lower copayment.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 $250 copayment for Medicare-covered surgery. You have been asked to pay a $250 copayment for an aspiration or injection of large joint. An aspiration or injection of large joint falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 foran aspiration or injection of large joint (20610) performed on March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does nothave to pay forthe domiciliary or rest home visit (99334) provided on April 20, 2020 by an out of network (OON) provider.You asked the Plan to pay fordomiciliary or rest home visit. You say that the services rendered were medically necessary.The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services by an out-of-network provider.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 networkproviders 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 forthe domiciliary or rest home visit (99334) provided on April 20, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the activities of daily living services provided from February 
18, 2020, to March 6, 2020. 
 
You asked the Plan to pay for the activities of daily living services. You say that this stay was due to the 
recommendation of your cardiologist. You also say that you received intensive physical and occupational 
therapy, and these services were approved. The Plan denied your request. The Plan says you signed an 
agreement for the staff to provide activities of daily living (custodial care), and also advises that if skilled 
nursing care was required, you would be transferred to a long-term facility. The Plan also says that custodial 
care is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered.  
 
We looked at the file and Medicare rules. You received assisted living services, which is non-skilled care. 
Based on this information, we decided that Medicare rules for coverage of the activities of daily living services 
have not been met. Therefore, we decided that the Plan does not have to pay for the activities of daily living 
services provided from February 18, 2020, to March 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant 360 testing provided to the enrollee. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria were not met. The enrollee had Guardant360 molecular 
pathology genomic profiling for a diagnosis of intrahepatic bile duct carcinoma. The Plan states there is a more 
appropriate code to describe the testing provided. The Plan states this is an administrative determination for 
coding and is not based on medical necessity. 
 
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 claim submitted is lack the 
appropriate codes for the services provided. Based on this information, we decided that Medicare rules for 
coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for 
Guardant 360 testing provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a vision exam provided by a participating 
provider on June 25, 2020. 
 
You asked the Plan to waive the copayment for a vision exam. You say that you thought you could go once a 
year for free. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for vision care/exam.  
 
You have been asked to pay a $40 copayment for a vision exam. A vision exam falls within the vision 
care/exam 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 vision exam provided by 
a participating provider on June 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent 
deep vein thrombosis. The Plan denied your request. The Plan says PCDs billed by E0675 are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. Additionally, PCDs billed by E0675 
are not covered. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that the hospital did not evaluate the areas that were 
denied. The Plan denied your request. The Plan says the enrollee is at or near functional baseline. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer 
found that the enrollee is non-ambulatory, and is totally dependent for all transfers and activities of daily living. 
Based on the records provided, her functional status is essentially unchanged from her prior level of function. 
There is no report of any medically unstable condition. There is no documentation that the enrollee requires 
skilled nursing or therapy services to safely and effectively provide medically necessary and reasonable 
treatment on a daily basis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on May 7, 2020. 
 
You asked the Plan to pay for the periodontal maintenance. You say that your last dental appointment was 
scheduled for November, but you were sick. You also say that your appointment was changed to December, 
and the May 7, 2020 appointment had already been scheduled as your routine visit. The Plan denied your 
request. The Plan says you were seen less than the allowed six months for your exam. 
 
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, cleanings are limited to once every 6 
months. The record shows that you received periodontal maintenance on December 4, 2019, and your cleanings 
benefit had been exhausted for the 6 month time period. Therefore, we decided that the Plan does not have to 
pay for the periodontal maintenance provided on May 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Computed Tomography of the Head or brain (70450) 
provided April 29, 2020. 
 
You asked the Plan to pay for the CT scan. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the service shares a Column I / Column II relationship with another code billed on 
the same date of service. 
 
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, we have confirmed that code 70450 
has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate 
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided 
that the Plan does not have to pay for Computed Tomography of the Head or brain (70450) provided April 29, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 20, 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 screening tests are not covered. 
 
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 tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover these 
tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99190) provided on March 26, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this 
service is included in the Part A DRG payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Payment for all fees related to this service would have been included under the facility claim. 
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on March 26, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to dermatology.You asked the Plan to pre-approvethese services. You say that you have a history of melanoma.The Plan denied your request. The Plan says the referral is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the referral is not medically necessary. Our physician reviewer found the submitted records do not contain any documentation of any current suspicious lesions. There is no documentation to support that a referral to a dermatologist is reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea referral to dermatology.