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

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on March 24, 
2020. 
 
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 Medicare billing criteria were not met. 
 
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 is not supported in the 
medical record. The procedure reports do not accurately describe the services billed. Medicare rules for 
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for 
physician services provided to the enrollee on March 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 23, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. 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 23, 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 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for irrigation of implanted venous access 
device for drug delivery systems (CPT Code 96523) on October 29, 2019 provided by the outpatient 
department. 
 
You asked the Plan to waive the copayment for the service. You say that you confirmed that you were billed 
incorrectly. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 
EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received irrigation of implanted venous access device for drug delivery 
systems (CPT Code 96523) in the outpatient department of the facility. The Medicare-allowed amount for the 
outpatient hospital services is less than the set $135 copayment; therefore, you have been asked to pay the 
lesser amount of $82.15 for the services. Your EOC states that enrollees must pay a $135 copayment for each 
visit for Medicare-covered outpatient hospital services not otherwise specified in this chapter. 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 irrigation of implanted venous access device for drug delivery 
systems (CPT Code 96523) on October 29, 2019 provided by the outpatient department.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit services (CPT 36415 and CPT 99211) provided 
to the enrollee on March 17, 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 a manifestation code was the primary listed diagnosis 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 the denied codes is: 
 
CPT 36415: 
 
collection of venous blood by venipuncture 
 
CPT 99211: 
 
Office or other outpatient visit for the evaluation and management of an established patient that may not 
require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are 
spent performing or supervising these services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
records provided indicate that claim 820201410195494 was submitted to the health plan with a primary 
diagnosis code of D63.1 - Anemia in chronic kidney disease. This code in the ICD10 manual gives instructions 
to first code the underlying chronic kidney disease (N18. ) category.  The claim does have N18.3 - Chronic 
kidney disease, stage 3 (moderate) noted but is not billed as the "Primary Diagnosis", therefore, this claim is 
not eligible for reimbursement based on how the provider submitted the diagnosis codes on the claim. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for office visit services (CPT 36415 and CPT 99211) provided to the enrollee on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit you had with a podiatrist on 
May 27, 2020. 
 
You asked the Plan to waive the copayment for the podiatry visit. You say that you went to this doctor to get 
your toenails clipped and that toenail clipping doesn't have a copayment. The Plan denied your request. The 
Plan says you were charged this copayment correctly.  The plan says that you received more services during 
this podiatry visit than just toenail clipping. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for podiatry visits.  
 
You have been asked to pay a $45 copayment for the podiatry visit. The medical records from this visit indicate 
that you had a full new patient exam in addition to toenail clipping. 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 you had with a podiatrist on May 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biopsy (88305) provided on March 4, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for an OON biopsy. You say that you have asked for a referral. The Plan denied 
your request. The Plan says this service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the biopsy (88305) provided on March 4, 2020 by 
an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (99283) on 
January 21, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you should not have any 
copayments. The Plan denied your request. The Plan says the correct copayments were 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 $120 
copayment for emergency care.  
 
You have been asked to pay a $120 copayment, minus a hospital "prompt payment" discount, for an emergency 
room visit. An emergency room visit falls within the "Emergency care" benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an emergency room visit (99283) on January 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy services (HCPCS S9328) provided to 
the enrollee from January 22, 2020 to March 11, 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 claim was processed appropriately. 
 
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 home infusion therapy services (HCPCS S9328) 
provided to the enrollee from January 22, 2020 to March 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 3, 2018 
to May 5, 2018. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be covered. The Plan 
denied your request. The Plan says the enrollee could have been treated at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found based on the provided documentation, there was no clear indication for inpatient 
services. The patient was referred to radiation oncology although there was no evidence of any need for this 
consultation as an inpatient. The vitals were stable, she was hemodynamically stable, and was not exhibiting 
severe uncontrolled pain to suggest a need for at least two midnights in the hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from May 3, 2018 to May 5, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Zoster (Shingles) Vaccination and administration (CPT Code 
90632) and (CPT Code 90471) provided April 23, 2019. 
 
You asked the Plan to pay for the services. You say that you are requesting reimbursement of services 
rendered. The Plan denied your request. The Plan says the request is not a covered benefit because there is no 
indication of injury or exposure, and thus this is a preventive vaccine. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. The request is for Zoster (Shingles) 
Vaccination and administration (90750 and 90471) on April 23, 2019. The diagnosis was encounter for 
immunization. This was noted to be the second dose in a two (2) part series. The request is not a covered 
benefit because there is no indication of injury or exposure, and thus this is a preventive vaccine. Therefore, we 
decided that the Plan does not have to pay for Zoster (Shingles) Vaccination and administration (CPT Code 
90632) and (CPT Code 90471) provided April 23, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health skilled nursing visit provided on March 3, 
2020. 
 
You asked the Plan to pay for the home health visit. You say that this is being denied incorrectly since it is not 
an episodic claim but a per visit claim. The Plan denied your request. The Plan says the procedure code/type of 
bill is inconsistent with the place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims are payable only on certain 
TOBs. 
 
TOB 0324 is not valid for Medicare home health billing. Therefore, we decided that the Plan does not have to 
pay for the home health skilled nursing visit provided on March 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 test provided to the enrollee on April 30, 
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 this was not medically indicated according to the test requisition. 
 
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 pay for the test. Our reviewer says that the requested 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found the 
documentation does not support that the Guardant360 genetic testing provided on 4/30/20 was medically 
reasonable and necessary for the enrollee in this case. The documentation does not support that the 
Guardant360 testing would impact the management and outcome of this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the test have not been met. Therefore, we decided that the Plan does not have to 
pay for the Guardant360 test provided to the enrollee on April 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Omeprazole, aspirin, Atorvastatin, Hydralazine, 
Metoprolol Succinate, Lisinopril, Magnesium Oxide, and Loperamide provided from March 26, 2020 to March 
28, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that it is unreasonable to expect someone 
rushing to the emergency room to pack up their medications from home. The Plan denied your request. The 
Plan says these drugs are self-administered, and are not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Omeprazole, aspirin, 
Atorvastatin, Hydralazine, Metoprolol Succinate, Lisinopril, Magnesium Oxide, and Loperamide provided 
from March 26, 2020 to March 28, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on February 3, 2020.

You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says the documentation submitted did not include documentation of whether the entire panel is being ordered, or only the selected drugs; therefore, the billed service cannot be verified.

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 HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed."

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the order requisition for the above test did not include which specific analytes or panels were ordered to be performed, and it was not signed. Therefore, the records do not support the coding of G0483.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on February 3, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a biopsy provided by a participating 
provider on May 11, 2020. 
 
You asked the Plan to waive the copayment for a biopsy. You say that this should be part of the assistance 
program benefit. 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 $295 
copayment for outpatient surgery.  
 
You have been asked to pay a $295 copayment for a biopsy. The correct copayment has been applied to the 
services that were provided. A biopsy falls within the outpatient surgery 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 biopsy provided by a participating provider on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99202) provided June 1, 2020. 
 
You asked the Plan to pay for the outpatient office visit. You say that you had a phone visit with the nurse 
practitioner to renew your medicines. Because of COVID19 you could not go into the office. You have been 
billed the $10 copay and that is all you should owe. The Plan denied your request. The Plan says the plan only 
covers manual manipulation of the spine to correct subluxation. This service is not covered under the plan 
benefits. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99202) provided June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visit with an otolaryngologist 
(ENT) and a hearing exam with an audiologist provided on June 2, 2020. 
 
You asked the Plan to waive the copayments for the ENT visit and the hearing exam with an audiologist. You 
say that these services were done at the same time, so there should only be one copayment applied. The Plan 
denied your request. The Plan says you were appropriately charged two separate copayments. 
 
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 specialist visits and a $40 copayment for diagnostic hearing exams.  
 
You have been asked to pay a $40 copayment for the ENT visit and a $40 copayment for the hearing exam with 
an audiologist. The ENT visit falls within the specialist visits benefit category. In addition, you had a hearing 
exam with a different provider (an audiologist).  These copayments can be assessed separately even if they 
occur on the same day. 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 office visit with an 
otolaryngologist (ENT) and a hearing exam with an audiologist provided on June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the orthopedist visit you had on May 21, 
2020. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you were blindsided by this 
charge and no one told you this doctor was no longer in the group. The Plan denied your request. The Plan says 
you were charged this copayment 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 $25 
copayment for services in a specialist's office.  
 
You have been asked to pay a $25 copayment for the specialist 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 orthopedist visit you had on May 21, 2020.