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

 
We decided that the Plan does not have to waive the copayment for arthrocentesis provieded. 
 
You asked the Plan to waive the copayment for arthrocentesis. You say that you disagree with the facility 
charges and feel that you should only owe a specialist copayment. The Plan denied your request. The Plan says 
the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for outpatient surgery, including services provided at hospital outpatient facilities.  
 
You received arthrocentesis, at an outpatient hospital facility. Arthrocentesis is considered an 
outpatient surgical procedure. Therefore, you are responsible to pay the $300 copayment.  
 
You have been asked to pay a $300 copayment for arthrocentesis. Arthrocentesis 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 for arthrocentesis provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction provided on July 6, 2020 by an OON provider. 
 
You asked the Plan to pay for the extraction. You say that you tried but were not able to get an appointment 
with an in-network provider. The Plan denied your request. The Plan says the service was rendered by a non-
participating provider. The Plan also says that you must use network providers to get your medical care and 
services. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
extraction provided on July 6, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 30, 2020, by an out-
of-network provider. 
 
You asked the Plan to pay for the medical services. You say that prior authorization was not possible at this 
time. The Plan denied your request. The Plan says the provider is out-of-network. The Plan states the services 
were not referred by a network provider or rendered in a participating facility. The Plan states 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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on June 30, 2020, 
by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 23, 2019, through 
August 27, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the 
laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation 
and/or claim history indicates that the specimen was obtained in an office setting POS 32. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, the claim indicates the specimen was 
collected in a laboratory setting while the record indicates the specimen was collected in an office setting. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on July 23, 2019, 
through August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 2, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that there is a medical necessity pre-established with 
the enrollee and the facility. The Plan denied your request. The Plan says prior authorization was not obtained, 
as required under the plan benefits. 
 
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 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 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 the medical services provided on October 2, 2020 by an out of network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded G0480, 36451, 86900, 86850, 
86901, 85025, 84520, 82565, 80051, 85610, 85730, 87641, 87640 and 81001 provided on July 5, 2019. 
 
You asked the Plan to pay for the laboratory 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 G0480, 36451, 86900, 86850, 86901, 85025, 84520, 82565, 80051, 85610, 85730, 
87641, 87640 and 81001 are not supported in the medical record. Specifically, the documentation submitted 
did not include laboratory results; therefore, the billed services cannot be verified. Based on this information, 
we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we 
decided that the Plan does not have to pay for the laboratory services coded G0480, 36451, 86900, 86850, 
86901, 85025, 84520, 82565, 80051, 85610, 85730, 87641, 87640 and 81001 provided on July 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on February 20, 2020, by 
an out-of-network provider. 
 
You asked the Plan to pay for the chiropractic services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the member self-referred to this 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 member does not have out-of-network benefits. The 
member would only have coverage for services obtained from a non-affiliated provider if there was an 
approved authorization on file. Additionally, chiropractic services require prior-authorization on the member?s 
plan. Since there was no authorization on file for the out-of-network chiropractic services rendered on February 
20, 2020 and the member was not referred by a participating provider, they are not eligible for coverage for this 
date of service. 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 chiropractic services provided 
on February 20, 2020, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodontal scalings and root planings and two 
gingival irrigations provided on October 12, 2020. 
 
You asked the Plan to pay for the scalings and planings and gingival irrigations. You say that you thought these 
services were covered. You also say that the provider never advised you that these services would not be 
covered. The Plan denied your request. The Plan says these services are not 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 two 
periodontal scalings and root planings and two gingival irrigations provided on October 12, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for hemodialysis (99512) provided on 
February 9, 2018, through July 14, 2018. 
 
You asked the Plan to pay for the home visit. You say that you would like reconsideration because this service 
was authorized by the Plan. The Plan denied your request. The Plan says there is not a valid Medicare ID on 
file for this facility. 
 
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 99512 is not supported in the medical record. Specifically, per Medicare, CPT code 
99512 has a status indicator of I. This means that CPT 99512 is not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of the home visit have not been met. Therefore, we 
decided that the Plan does not have to pay for the home visit for hemodialysis (99512) provided on February 9, 
2018, through July 14, 2018.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the 
abdomen/pelvis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is noted to have pulmonary 
nodules dating to at least April of 2019. Repeat imaging in April of 2020 showed that the nodules were stable. 
While another imaging study to monitor the nodules may be reasonable, the time frame does not appear to be 
appropriate, given the year?s long period prior to the April 2020 imaging and the lack of documented new or 
worsening symptoms. The enrollee is noted to have had an incompletely visualized liver lesion on April 2020 
imaging.  There is no documentation that this issue has been further evaluated. While imaging of the liver is 
certainly warranted, imaging of the pelvis is not currently shown to be medically necessary. Therefore, the 
requested CT of the abdomen and pelvis is not medically necessary and reasonable. 
 
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-approve a computed tomography (CT) scan of the abdomen/pelvis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retainer crowns (D6750) for teeth # 10 and 11, and the 
pontics (D6240) for teeth # 8 and 9 provided on August 27, 2020. 
 
You asked the Plan to pay for the dental services. You say that your bridge has cracked. You say that you need 
to have it replaced. You say that it is strange that the services were denied because you require the bridge to eat 
properly and to stay healthy. The Plan denied your request. The Plan says there is an annual maximum benefit 
of $1,000 for covered dental services. The Plan also says that the annual maximum has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the annual maximum benefit of $1,000 
has been exhausted. 
 
Date of Service CPT Code Total Billed Total Allowed Plan Paid Your Responsibility 
3/4/20 D0140 $92 $47 $47 $0 
 D7210 $303 $147 $73.50 $73.50 
8/27/2020 D0150 $65 $50 $50 $0 
 D0210 $85 $81 $81 $0 
 D6750 (#6) $920 $769 $384.50 $384.50 
 D6750 (#7) $920 $769 $364 $405 
TOTAL:    $1,000 $863 
 
Therefore, we decided that the Plan does not have to pay for the retainer crowns (D6750) for teeth # 10 and 11, 
and the pontics (D6240) for teeth # 8 and 9 provided on August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 30, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the procedure needed to be performed due to the 
enrollee's condition. The Plan denied your request. The Plan says the services were not urgent, emergent, or 
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 file shows that the enrollee received lumbar epidural steroid injections. The 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 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 the medical services 
provided on June 30, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an automatic external defibrillator (AED) garment (LifeVest) 
provided on June 23, 2020. 
 
You asked the Plan to pay for AED garment. You say that the enrollee was discharged home on this date and 
was wearing this equipment. The Plan denied your request. The Plan says the denial of payment for this item is 
correct, because the enrollee was a hospital inpatient from June 19, 2020 to June 24, 2020 so the Plan does not 
make separate payment for this DMEPOS item. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not make separate payment for 
DMEPOS when a beneficiary is in a Part A inpatient stay.  
 
We looked at the file and Medicare rules. This item was provided during a hospital inpatient stay; therefore, the 
Plan does not make separate payment for this item. Based on this information, we decided that Medicare rules 
for coverage of AED garment have not been met. Therefore, we decided that the Plan does not have to pay for 
an automatic external defibrillator (AED) garment (LifeVest) provided on June 23, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan of chest without contrast for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this can be performed for persistent chest pain if the initial chest x-ray reveals no 
abnormalities. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee has had 
symptoms for over one year. The two view chest x-ray was normal on 1/6/20. The presumptive diagnosis is 
costochondritis. The CT of the chest is the next step in workup, and should be approved. The plan's condition 
of approval has already been met with a two view chest x-ray of 1/6/20. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
CT scan of chest without contrast for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on February 25, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the enrollee failed to advise you that her 
insurance coverage changed. The Plan denied your request. The Plan says there are participating providers in 
the enrollee's area to choose from. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide physical therapy services. 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 the physical therapy services provided on February 25, 2020 by an out of network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on May 21, 2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says to report 
comprehensive genomic profile testing, service providers should use CPT code 81479. 
 
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 looked at the file and the rules. The claim provided does not show that the testing at issue has been billed 
based on applicable guidelines. Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for the gene panel provided on May 21, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the facility fee provided on August 7, 
2020. 
 
You asked the Plan to reduce the copayment for the facility fee. You say that you had the same procedure last 
year and only paid a $40 copayment. The Plan denied your request. The Plan says the claim was reprocessed 
and you have been charged 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 $250 
copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient 
facility.  
 
You have been asked to pay a $250 copayment for the facility fee. The facility fee 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 reduce the copayment for the facility fee provided on August 7, 2020. 
 
Our decision is only about the August 7, 2020 service. If you have any questions about prior years billing, 
please contact the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on June 10, 2020. 
 
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says Medicare does not make separate 
payment for this 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. The rules also say that all services integral to 
accomplishing a procedure are considered bundled into that procedure and, therefore, are considered a 
component part of the comprehensive code. 
 
We find that CPT code 95999 is not supported in the medical record. Specifically, train of four monitoring is 
considered integral to the primary procedure and not separately payable. Based on this information, we decided 
that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that 
the Plan does not have to pay for train of four monitoring (95999) provided on June 10, 2020.