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

 
We decided that the Plan has to pay for the office visit rendered on January 23, 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 that procedure code 99213 is inclusive to code 95004 and not separately payable. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that code 99213-25 is not separately payable because it is 
inclusive to billed code 95004; however, there are no National Correct Coding Initiative (NCCI) edits to 
support that these codes are not separately payable. The Plan has not provided any further documentation or 
Medicare rules to support that the code is not payable as billed. Therefore, we decided that the Plan has to pay 
for the office visit rendered on January 23, 2020.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care discharge day management (CPT Code 
99217) provided to the enrollee on February 4, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the auto insurance paid for the claim. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Based on the auto explanation of 
benefits attached to the appeal, the auto insurance paid the provider $148.42 with the explanation 305 - Our 
payment for this service has been based upon the applicable policy language and is no more than the amount 
provided for by the schedule of maximum charges contained in the Florida No-Fault Act, including the use of 
Medicare coding policies and payment. The Plan correctly processed date of service February 4, 2020. 
Payment is calculated taking into consideration the payment made by the auto carrier and The Plan's allowable 
amount. Combined, the auto carrier payment and the Plan?s payment should not exceed the Plan's normal 
allowable amount.  The auto insurance paid $148.42 therefore, the Plan's responsibility was $0.00. Therefore, 
we decided that the Plan does not have to pay for observation care discharge day management (CPT Code 
99217) provided to the enrollee on February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 9, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist visits provided from March 25, 
2020 to May 20, 2020. 
 
You asked the Plan to waive the copayments for specialist visits. You say that you thought that telehealth visits 
would not have a copayment due to COVID-19. 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 $40 
copayment per specialist visit.  
 
You received specialist visits from March 25, 2020 to May 20, 2020 for a total of 4 visits. Therefore, you are 
responsible to pay a $40 copayment per each visit. The total amount you owe is: $40 (copayment) x 4 (visits) = 
$160.  
 
You have been asked to pay the total copayment amount of $160 for specialist visits. Specialist visits fall 
within the physician/practitioner services, including doctor?s office visits benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayments for specialist visits provided from March 25, 2020 to May 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on 
May 27, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that the Plan advised the 
provider that these services would be covered. You also say that you cannot afford this bill. The Plan denied 
your request. The Plan says the treating provider is not currently enrolled in Medicare. 
 
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 except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the periodic oral evaluation and prophylaxis provided on May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, maxillary partial denture, and addition of 
tooth to an existing partial denture provided on February 11, 2020 by an OON provider. 
 
You asked the Plan to pay for the extraction, maxillary partial denture, and tooth addition. You say that these 
services were an emergency, and urgently needed. The Plan denied your request. The Plan says these services 
were rendered by a non-participating provider. The Plan also says that you must use network providers to 
receive dental 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, maxillary partial denture, and addition of tooth to an existing partial denture provided on February 
11, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and additional 
intraoral periapical x-ray (D0230) provided on February 10, 2020. 
 
You asked the Plan to pay for the intraoral periapical x-rays. You say that your card does not mention that you 
need to go to a specific office for this provider to give you x-rays and a teeth cleaning. The Plan denied your 
request. The Plan says these services are not covered benefits under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 first 
intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) provided on February 10, 
2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endoscopy rendered on October 15, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 31237 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 31237 is nasal/sinus endoscopy, surgical; with biopsy, 
polypectomy or debridement (separate procedure). 
 
We find that CPT code 31237 is not supported in the medical record. Specifically, there is no documentation of 
a nasal/sinus endoscopy with biopsy. Based on this information, we decided that Medicare rules for coverage 
of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
endoscopy rendered on October 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation, prophylaxis, and 
bitewings provided on February 24, 2020 by an OON provider. 
 
You asked the Plan to pay more for the comprehensive oral evaluation, prophylaxis, and bitewings. You say 
that prior to your appointment, you contacted the Plan and were only told about the $1,000 limit for dental 
services. You also say that you were not informed about the concept of the allowable amount. The Plan denied 
your request. The Plan says the enrollee liability was applied correctly, per your plan 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, you are responsible for the difference 
between the billed amounts and allowed amounts for services received OON. The records show that you were 
also given correct information about your dental benefits during the call on January 2, 2020. Therefore, we 
decided that the Plan does not have to pay more for the comprehensive oral evaluation, prophylaxis, and 
bitewings provided on February 24, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 13, 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 not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 panel rendered on March 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the ambulance transport provided on April 2, 
2020. 
 
You asked the Plan to waive the copay for the ambulance transport. You say that you did not have an 
ambulance ride. The Plan denied your request. The Plan says that you have a $250 copay per Medicare covered 
ground ambulance trip. 
 
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 
copay for ground ambulance services.  
 
You have been asked to pay a $233.25 copay for the ambulance transport. The ambulance transport falls within 
the ground ambulance services benefit category. This means that you have been asked to pay less than 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 copay for 
the ambulance transport provided on April 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 17, 2018 by an 
non-contracted provider. 
 
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 services were rendered by a non-contracted provider without prior authorization. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the medical services provided on December 17, 2018 by an non-contracted provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
February 7, 2020 to February 8, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you did not know you 
would be charged $395 per night for a hospital stay. You say you cannot afford this copayment. The Plan 
denied your request. The Plan says 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 $395 
copayment for each day for days 1 to 4 for in-network Medicare-covered hospital care and a $0 copayment for 
additional Medicare-covered days.  
 
You have been asked to pay a $395 copayment for the inpatient hospital stay. The inpatient hospital stay falls 
within the ?Inpatient hospital 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 
the inpatient hospital stay provided from February 7, 2020 to February 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management; 30 minutes or less (CPT 
Code 99238) provided to the enrollee on October 17, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 99238 is not supported in the medical record. Specifically, the documentation submitted 
does not include a hospital discharge day management note with a recorded duration of time of 31 minutes or 
more for the billed date of service of October 17, 2019; therefore, the billed service cannot be verified. It is 
noted that multiple attempts were made to contact the provider for additional information. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Please note dates 
of service October 01, 2019 to October 02, 2019 has been previously paid to provider on February 12, 2020. 
Dates of service October 07, 2019 to October 11,2019 have been addressed under another case. Therefore, we 
decided that the Plan does not have to pay for hospital discharge day management; 30 minutes or less (CPT 
Code 99238) provided to the enrollee on October 17, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on February 23, 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 not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 panel rendered on February 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chemotherapy injections provided 
from April 1, 2020 to April 22, 2020. 
 
You asked the Plan to waive the coinsurance for the chemotherapy injections. You say that you would like your 
bills reviewed. You say nothing changed to your treatments. The Plan denied your request. The Plan says 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 20% 
coinsurance for Medicare Part B chemotherapy drugs and other Medicare Part B drugs.  
 
You have been asked to pay $594.06 which is 20% of the allowed amount for the chemotherapy injections on 
each date of service. The allowed amount is $2,970.28. ($2,970.28 x 20% = $594.06) ($594.06 x 3 dates of 
services = $1,782.18). The chemotherapy injections fall within the Medicare Part B prescription drugs 
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 coinsurance for the chemotherapy injections 
provided from April 1, 2020 to April 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 11, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on December 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection provided on March 3, 2020.
You asked the Plan to waive the copayment for the injection. You say that you were not aware of the $250 copayment which you cannot afford and you do not agree you should pay. The Plan denied your request. The Plan says 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 $295 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $295 copayment for the injection.
You have been asked to pay a $250.82 copayment for the injection. The injection falls within the "Outpatient Surgery and Other Medical 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 the injection provided on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 10, 2019 to
September 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the medical services. You say that you were told that this would be covered. The
Plan denied your request. The Plan says these services were provided by an out of network doctor and no
authorization was sought to be treated out of network.
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 September 10,
2019 to September 24, 2019 by an out of network (OON) provider.