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

 
We decided that the Plan has to pay for skilled nursing facility (SNF) care provided February 13, 2020 to 
February 19, 2020. 
 
You asked the Plan to pay for SNF care. You say that the services were medically necessary. The Plan denied 
your request. The Plan says that coverage criteria was not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that skilled 
nursing services were medically necessary. Our physician reviewer found the documentation supports that the 
enrollee was likely to benefit from skilled therapy services. The documentation supports that the enrollee 
required skilled services on a daily basis on an inpatient basis in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pay for skilled nursing 
facility (SNF) care provided February 13, 2020 to February 19, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0427) provided 
on February 19, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you thought there was no 
copayment for this service and you cannot afford to pay this bill. 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 $175 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $175 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 (A0427) provided on 
February 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the services provided on March 16, 2020. 
 
You asked the Plan to waive the copayment for the outpatient clinic visit (G0463) and injection procedure 
(20551). You say that the copayment for an x-ray is wrong. The Plan denied your request. The Plan says you 
have been 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 $295 
copayment for Hospital Outpatient Facilities and Ambulatory Surgical Centers.  
 
You have been asked to pay $295 copayment for the outpatient clinic visit (G0463) and injection procedure 
(20551). The outpatient clinic visit (G0463) and injection procedure (20551) fall within the Hospital Outpatient 
Facilities and Ambulatory Surgical Centers services benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the services provided on March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provided on February 20, 2020, and February 21, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 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 to the enrollee by an out-of-network provided 
on February 20, 2020, and February 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services you received on January 24, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted 
out of 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 services you received on January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 11, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the rest home visit (99336). You say that you would like reconsideration because 
the provider relies on the facility to obtain proper permissions. The Plan denied your request. The Plan says the 
services were received by a non-contracted provider in the Plan service area, were not for an urgent or 
emergent reason, were available to be provided in-network and were not authorized as required. 
 
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 February 11, 
2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided to you from March 6, 2019, to 
July 22, 2019. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. The Plan covers only oral exams, cleanings, fluoride and x-rays. Therefore, 
we decided that the Plan does not have to pay for the dental services provided to you from March 6, 2019, to 
July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits you had on February 22, 2020 
and February 29, 2020 with your primary care doctor. 
 
You asked the Plan to waive the copayment for the office visits. You say that you scheduled an appointment 
with your doctor on February 22, 2020 with your doctor because you had COVID-19 symptoms.  You were 
examined and advised to take over-the-counter medications.  Your symptoms persisted, so you returned to your 
doctor on February 29, 2020.  You claim that you were told that you likely had COVID-19 but that no tests 
were available.  You say that there should be no copayment for COVID-19-related care. The Plan denied your 
request. The Plan says you were charged these copayments correctly.  The Plan says that the medical records 
from these two dates of service do not indicate that these visits were COVID-19-related.  Rather your medical 
records show that you were seen for sore throat and a sinus infection.  The Plan says that you received no 
COVID-19 testing. 
 
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 $35 
copayment for primary care office visits.  
 
You have been asked to pay a $35 copayment for each of the office visits. 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. In addition, there is nothing in your contract or Medicare 
rules that says that office visit copayments related to COVID-19 are to be waived.  Rather, Medicare guidance 
states that only COVID-19-related lab tests are to be covered at no cost. The services in question were not lab 
tests, but office visits, and there is no diagnosis of COVID-19 in your medical records. Therefore, we decided 
that the Plan does not have to waive the copayment for office visits you had on February 22, 2020 and February 
29, 2020 with your primary care doctor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmology visit provided on 
December 3, 2019. 
 
You asked the Plan to waive the copayment for the ophthalmology visit. You say that this charge should be 
waived since the visit was as a result of complications from cataract surgery. The Plan denied your request. The 
Plan says this copayment was charged correctly.  The Plan says that this visit was not related to cataract 
surgery, but rather, for treatment of squamous blepharitis of the right lower eyelid. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $35 copayment for visits with a specialist.  
 
The enrollee has been asked to pay a $35 copayment for the ophthalmology visit. An ophthalmologist is a 
specialist, so the specialist visit copayment applies. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the ophthalmology visit provided on December 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, chest; single view (CPT Code 
71045-26) provided on May 26, 2020. 
 
You asked the Plan to pay for the x-ray. You say that the member had multiple exams on this date of service. 
The Plan denied your request. The Plan says the Medicare rules have not been 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. 
 
CPT Code 71045-26 is a column II procedure to the column I procedure, 74022 (Radiologic examination, 
complete acute abdomen series, including 2 or more views of the abdomen) billed by another provider under a 
different claim number. Both providers are within the same group and have the same primary specialty. Per 
CMS CCI PTP edits, CPT code 71045 is the column II code to the more comprehensive column I code 74022 
but a modifier is allowed in order to differentiate between the services provided. Per review of medical records, 
71045 is supported as separate and distinct from procedure code 74022 that was performed. However, an 
appropriate modifier to represent the services as separate and distinct was not used. Therefore, the 
recommendation for CPT code 71045-26 is to uphold the original denial. Based on this information, we 
decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan 
does not have to pay for radiologic examination, chest; single view (CPT Code 71045-26) provided on May 26, 
2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (code 99215) provided on March 14, 2020. 
 
You asked the Plan to pay for office visit. You say that the place of service and procedure code combination 
has been deemed appropriate. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the code billed on this claim is not appropriate for the place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that any physician seeing a patient registered in an 
emergency department may use emergency department visit codes, however if the physician asks the patient to 
meet him/her in the emergency department as an alternative to an office and the patient is not registered as a 
patient in the emergency department, the physician should bill the appropriate office/outpatient visit code.  
 
We looked at the file and Medicare rules. This enrollee presented to the emergency department and was 
registered as a patient in the emergency department. This visit was not performed using the emergency 
department as an alternative to an office. Therefore, the use of office visit code 99215 is not appropriate for this 
claim. Based on this information, we decided that Medicare rules for coverage of office visit have not been 
met. Therefore, we decided that the Plan does not have to pay for an office visit (code 99215) provided on 
March 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (93010) provided January 20, 2020. 
 
You asked the Plan to pay for an electrocardiogram. You say that you would like separate payment for this 
service. The Plan denied your request. The Plan says the billed code 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. 
 
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 an electrocardiogram. Our reviewer says that 
the billed code does not meet criteria for separate reimbursement. Our physician reviewer found the medical 
records submitted do not include a complete, written report similar to that which would be prepared by a 
specialist in the field, therefore this service is not separately reimbursable. Payment is bundled in the 
emergency room visit of 99285, which was performed for the same date of service by a physician in the same 
group/practice and the health plan paid for service 99285. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electrocardiogram have not been met. Therefore, we decided that the Plan 
does not have to pay for an electrocardiogram (93010) provided January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 12, 2020 by an out-of-
network provider. 
 
You asked the Plan to pay for the medical services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says you do not have out-of-network benefits and there 
was no authorization on file for the 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 May 12, 2020 by 
an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting of 
computed tomography provided on March 5, 2020. 
 
You asked the Plan to pay for the 3D rendering with interpretation and reporting of computed tomography 
(76377). You say that the Plan should pay this claim. The Plan denied your request. The Plan says 3D 
rendering with interpretation and reporting of computed tomography requires that an accompanying CT 
procedure be reported by the same or different provider. 
 
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 76377 is 3D rendering with interpretation and reporting 
of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
post processing under concurrent supervision; requiring image post processing on an independent workstation. 
 
 
 
 
 
 
 
 
We find that CPT code 76377 is not supported in the medical record. Specifically, the records do not support 
that a 3D rendering was performed. Based on this information, we decided that Medicare rules for coverage of 
the 3D rendering with interpretation and reporting of computed tomography (76377) have not been met. 
Therefore, we decided that the Plan does not have to pay for the professional component of a Low Dose CT 
scan for lung cancer screening and 3D rendering with interpretation and reporting of computed tomography 
provided on March 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the limited oral evaluation, intraoral x-rays and resin-
based composite provided on May 4, 2020. 
 
You asked the Plan to pay more for the limited oral evaluation, intraoral x-rays and resin-based composite. You 
say that you have dental coverage up to $1,000. You say that the claim should be evaluated because it was 
within your benefit limit. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 is only obligated to pay the 
allowed amount for your covered dental services from an out-of-network provider. The Plan paid for an oral 
evaluation on February 28, 2020 which exhausted your benefit. The Plan also paid the allowed amount for the 
intraoral x-rays and resin-based composite. You are responsible for the remaining amount. 
 
Service Billed Amount Allowed 
Amount 
Plan Paid Difference of 
Billed & Allowed 
Amount 
Member 
Liability 
Oral Evaluation $99 $0 $0 $99 $99 
Intraoral X-Rays $60 $20 $20 $40 $40 
Composite $368 $100 $100 $268 $268 
TOTAL:     $407 
Therefore, we decided that the Plan does not have to pay more for the limited oral evaluation, intraoral x-rays 
and resin-based composite provided on May 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 28, 2019 to April 
4, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration because 
you were informed that you would not have to pay out of pocket for these services. The Plan denied your 
request. The Plan says these services were rendered by an out-of-network provider and out-of-network services 
require prior authorization. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Additionally, the only chiropractic service covered by the Plan is manual manipulation of the spine to correct a 
subluxation. Therefore, we decided that the Plan does not have to pay for the medical services provided on 
February 28, 2019 to April 4, 2019 by an out of network (OON) provider.  
 
Your complaint about being given incorrect information is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital physician visit provided on December 4, 2018. 
 
You asked the Plan to pay for physician visit. You say that you are requesting that the claim be reprocessed. 
The Plan denied your request. The Plan says the denial of payment for this service is correct, because this claim 
was not submitted within the timely filing limit. 
 
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 physician visit was not filed until January 28, 2020. 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 a hospital physician visit provided on December 4, 2018.