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

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 12, 
2020 by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the servicing provider depends 
upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance 
company. You also say that the services were medically necessary. The Plan denied your request. The Plan 
says the services were rendered by an OON provider, and requires prior authorization. The Plan also says that 
medical records were never received. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan may require enrollees to obtain 
authorization before receiving services. The rules also say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
 
 
 
We looked at the file and Medicare rules. The record shows that the Plan requested medical records multiple 
times, but did not receive any additional information. Based on this information, we decided that Medicare 
rules for coverage of the subsequent nursing facility care have not been met. Therefore, we decided that the 
Plan does not have to pay for the subsequent nursing facility care provided on March 12, 2020 by an OON 
provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you do not believe you 
should be charged this copayment. The Plan denied your request. The Plan says you were charged this cost 
sharing 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 $125 
copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $125 for these 
services. 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 ambulance services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 30, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that the member was in a nursing home setting at 
the time of services. You state it is not possible to request authorization before services are rendered. The Plan 
denied your request. The Plan says this provider is a non-network provider who does not work with the 
members health plan, and the member was referred by another provider who also does not work with the 
members health plan. The Plan states the member's primary care physician did not refer for services. 
 
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 January 30, 2020 
by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 27, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were transferred four (4) 
miles and were billed an incorrect amount for the transport. The Plan denied your request. The Plan says the 
claim was processed accordingly with your 2020 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 ambulance services provided on March 27, 2020. You are asked to 
pay a $275 copayment for the ambulance services. Your EOC states that enrollees must pay a $275 copayment 
for each Medicare-covered one-way trip via ground ambulance. 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 ambulance services provided on March 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and lab service provided on March 30, 2018. 
 
You asked the Plan to pay for the office visit and lab service. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim was not filed timely 
per Medicare criteria. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the office visit and lab service was not filed until May 21, 2019. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the office visit and lab service provided on March 30, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on February 3, 2020 to February 7, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with 
these charges. 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 $380 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $380 copayment per day for days 1-5. There is a $0 copayment for additional 
days 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 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 inpatient hospital stay provided by a 
participating provider on February 3, 2020 to February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 6, 
2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the documentation supports the 
medical necessity. The Plan denied your request. The Plan says this service requires prior authorization from 
non-par providers and there are no medical records or clinical documentation for review. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment.   
 
We looked at the file and Medicare rules. The file shows that you did not submit sufficient information to 
justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the 
subsequent nursing facility care have not been met. Therefore, we decided that the Plan does not have to pay 
for subsequent nursing facility care provided on March 6, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department visit provided 
on April 7, 2020. 
 
You asked the Plan to waive the copayment for the emergency department visit. You say that you would like 
the plan to reconsider their decision. The Plan denied your request. The Plan says the services were processed 
correctly per your plan 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). Your contract with the Plan clearly says that you must pay a $100 
copayment for emergency care.  
 
You have been asked to pay a $100 copayment for the emergency department visit. The emergency department 
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 
the emergency department visit provided on April 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional resin-based composite provided on February 
26, 2020. 
 
You asked the Plan to pay for the additional resin-based composite. You say that you have gone to this dentist 
for 60 years and did not know about in or out-of-network. You say that the claim should be reprocessed. The 
Plan denied your request. The Plan says two fillings are approved at the in-network benefit. 
 
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 also have a maximum benefit of 
two fillings per year. The Plan paid for two fillings at the in-network rate provided on February 26, 2020, 
which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the additional resin-
based composite provided on February 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trigger point injections (20553). 
 
You asked the Plan to pre-approve the trigger point injections. You say that you would like reconsideration 
because this service is medically necessary. The Plan denied your request. The Plan says per phone calls with 
the provider, trigger point injections are not the intended course of treatment. 
 
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 the trigger point injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found  
 
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 trigger point injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve trigger point injections (20553).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 16, 
2020 by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the servicing provider depends 
upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance 
company. You also say that the services were medically necessary. The Plan denied your request. The Plan 
says the services were rendered by an OON provider, and requires prior authorization. The Plan also says that 
medical records were never received. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan may require enrollees to obtain 
authorization before receiving services. The rules also say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
 
 
 
We looked at the file and Medicare rules. The record shows that the Plan requested medical records multiple 
times, but did not receive any additional information. Based on this information, we decided that Medicare 
rules for coverage of the subsequent nursing facility care have not been met. Therefore, we decided that the 
Plan does not have to pay for the subsequent nursing facility care provided on March 16, 2020 by an OON 
provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care on March 13, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
the provider is out-of-network and there is no prior authorization on file. 
 
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 subsequent nursing facility care on March 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MRI, breast, without and with contrast material(s), 
including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic 
analysis), when performed; bilateral (CPT Code 77049) provided on May 6, 2020. 
 
You asked the Plan to pay for the MRI. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not supported in the medical records received. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 pay for the MRI. Our physician reviewer found per 
CMS criteria, LCD BREAST Imaging: BREAST Echography (Sonography)/BREAST MRI/Ductography 
(L33585): BREAST MRI studies are to be used very selectively. The modality should be restricted to: cases 
where diagnosis is inconclusive, even after standard work-up; evaluation of the post-operative patient when 
scar tissue cannot be differentiated from tumors; patients with positive axillary nodes but no known primary; 
patients with rupture of a BREAST implant; or determination of the extent of disease in patients with known 
malignancy, prior to treatment (to assure confinement to one segment of the BREAST)... Per review of the 
medical record, there is no documentation supporting L33585 criteria is met. The review has determined that 
the requested services are not supported in the medical records received. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pay for the MRI, breast, without and with contrast material(s), including computer-aided detection (CAD 
real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral (CPT 
Code 77049) provided on May 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four bone replacement grafts for ridge preservation, four 
alveoloplasties in conjunction with extractions, and eighteen extractions. 
 
You asked the Plan to pre-approve the bone replacement grafts, alveoloplasties, and extractions. You say that 
these services are medically necessary. The Plan denied your request. The Plan says bone replacement graft for 
ridge preservation and alveoloplasty in conjunction with extractions are not covered benefits. The Plan also 
says that your extractions benefit has been exhausted for the plan year. 
 
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, bone replacement graft for ridge 
preservation and alveoloplasty in conjunction with extractions are not among those covered under this benefit. 
The contract clearly states that extractions are limited to 1 simple extraction per year. The records show that 
you were approved to receive 1 extraction on July 13, 2020, and your extractions benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pre-approve four bone replacement grafts for ridge 
preservation, four alveoloplasties in conjunction with extractions, and eighteen extractions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation and panoramic 
x-ray provided on February 11, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and panoramic x-ray. You say that 
sometimes you cannot go to a dentist that is in-network. The Plan denied your request. The Plan says you were 
issued a $500 reimbursement on June 9, 2020. The Plan also says that you have already received the maximum 
amount of coverage allowed. 
 
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 Plan offers a $500 allowance every 
year for Non-Medicare covered preventive dental services and Non-Medicare covered comprehensive dental 
services combined. You are responsible for any amount above the dental coverage limit. The record shows that 
you met the annual maximum benefit while processing this claim for the February 11, 2020 date of service, and 
your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the problem focused limited oral evaluation and panoramic x-ray provided on February 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 20, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z Code identifier should be entered adjacent to the 
CPT code in the comment/narrative field. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the Guardant360 testing provided on April 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hot or cold pack therapy (CPT Code 97010), mechanical 
traction therapy (CPT Code 97012) and electric stimulation therapy (CPT Code 97014) provided from 
February 11, 2020 through March 11, 2020. 
 
You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied 
charges. The Plan denied your request. The Plan says the services are not covered by the plan as an additional 
benefit. 
 
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. These services are not 
covered by the Plan or Medicare. Your EOC states that the covered service include: manual manipulation of 
the spine to correct subluxation. Therefore, we decided that the Plan does not have to pay for hot or cold pack 
therapy (CPT Code 97010), mechanical traction therapy (CPT Code 97012) and electric stimulation therapy 
(CPT Code 97014) provided from February 11, 2020 through March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 99152 provided on November 8, 2019. 
 
You asked the Plan to pay for CPT code 99152. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
 
 
 
 
 
 
 
 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the medical record does not 
contain evidence that moderate sedation was performed with the presence of an independent trained observer. 
Based on this information, we decided that Medicare rules for coverage of CPT code 99152 have not been met. 
Therefore, we decided that the Plan does not have to pay for CPT code 99152 provided on November 8, 2019.