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

 
We decided that the Plan does not have to pay for an abdominal x-ray (74019) provided on May 17, 2020. 
 
You asked the Plan to pay for the x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says CPT code 74019 is the column II code the column I 
code 74022 which has been processed and paid. 
 
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, we have confirmed that code the x-
ray has a bundled relationship with code 74022 and cannot be paid as billed. This code cannot be paid as a 
separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for an abdominal x-ray (74019) provided on May 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating 
provider on April 29, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. 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 $275 
copayment for outpatient diagnostic tests/advanced imaging services/outpatient hospital.  
 
You have been asked to pay $234.52 which is less than your copayment amount of $275 for a CT scan. A CT 
scan falls within the outpatient diagnostic tests/advanced imaging services/outpatient hospital benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for a CT scan provided by a participating provider on April 29, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic parenteral drug (D9610) provided on June 17, 
2020. 
 
You asked the Plan to pay for the dental service. You say that you had an extraction. You also say that you 
needed the general anesthesia due to your hypertension. The Plan denied your request. The Plan says 
therapeutic parenteral drug is not listed as a covered service. 
 
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 
therapeutic parenteral drug (D9610) provided on June 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a protective body sock (L1984), hip orthosis and addition 
(L1686 and L2624) provided on November 5, 2019. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did 
not include a valid physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. 
Specifically, the physician order in the documentation submitted is dated well after the billed date of service. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a protective body sock (L1984), hip orthosis and 
addition (L1686 and L2624) provided on November 5, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular genetic screening testing services provided on 
January 3, 2020. 
 
You asked the Plan to pay for the molecular genetic screening testing. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the molecular genetic 
screening testing services provided on January 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for air ambulance services provided on 
February 13, 2020. 
 
You asked the Plan to waive the coinsurance for air ambulance services. You say that the services were 
unnecessary and you disagree with the charges. 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 20% 
coinsurance for air ambulance services.  
 
You received air ambulance services on February 13, 2020. The total allowed amount is $6,184.19 and 20% of 
that is $1,236.84.  
 
You have been asked to pay the total coinsurance amount of $1,236.84 for air ambulance services. Air 
ambulance services fall within the air ambulance 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 coinsurance for air ambulance services provided on February 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on June 4, 2020. 
 
You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers 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 
home health services. 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 home health services provided on June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist services and an ultrasound 
provided on June 8, 2020. 
 
You asked the Plan to waive the copayments for specialist services and an ultrasound. You say that you are 
being balance billed an additional $30. 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 $30 
copayment for specialist visits a. Your contract with the Plan also clearly says that you must pay a $30 
copayment for basic radiology provided in a specialist's office. 
 
You received specialist services on June 8, 2020. Therefore, you are responsible to pay the $30 copayment.  
 
You received an ultrasound on June 8, 2020. Therefore, you are responsible to pay the $30 copayment.  
 
The total amount you owe is: $60.   
 
You have been asked to pay the total copayment amount of $60 for specialist services and an ultrasound. 
Specialist services fall within the physician/practitioner services, including doctor's office visits benefit 
category. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 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 services and an ultrasound provided 
on June 8, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services received 
November 15, 2019 to November 18, 2019. 
 
You asked the Plan to pay for the SNF services. 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. 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 looked at the file and Medicare rules. Review of the file shows that the services the enrollee received were 
billed with an invalid Health Insurance Prospective Payment System (HIPPS) code and a corrected claim from 
the provider is required. Based on this information, we decided that Medicare rules for coverage of the SNF 
services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing 
facility (SNF) services received November 15, 2019 to November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office outpatient visit (99214) provided on March 2, 
2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the services rendered were medically necessary. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an 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 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 office outpatient visit (99214) provided on 
March 2, 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 enteral feeding supplies (B4035, B4152) provided from 
January 3, 2020, to February 1, 2020. 
 
You asked the Plan to pay for enteral feeding supplies. You say that this was medically necessary. The Plan 
denied your request. The Plan says there is not a valid order for these supplies. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid order, proof of delivery for the supplies provided in this case. An order for 
the supplies at issue was not included in the submitted documentation. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for enteral feeding supplies (B4035, B4152) provided from January 3, 2020, to February 
1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and risk 
assessment (D0601) provided on May 27, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation (D0150) and risk assessment (D0601). You 
say that you are appealing because you are not a new customer, the doctor didn't tell you what you had and you 
don't know what procedure was provided. The Plan denied your request. The Plan says a comprehensive oral 
evaluation is covered once every three plan years and the risk assessment is not a covered 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 
one comprehensive oral evaluation every three plan years. The Plan paid for a comprehensive oral evaluation 
provided on November 26, 2019, which exhausted your benefit. The risk assessment is not a covered benefit. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and 
risk assessment (D0601) provided on May 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthotics rendered on March 11, 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 claims were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that claims billed without the KX modifier will be rejected. 
 
We looked at the file and Medicare rules. The file shows that the claims for the orthotics were not billed with 
the KX modifier. 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 orthotics rendered on March 11, 
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for parenteral nutrition solution provided from December 19, 
2019, to December 24, 2019. 
 
You asked the Plan to pay for the provided services. The Plan denied your request. The Plan says the billed 
services cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 30 units of CPT code B4185 are not supported in the medical record. Based on the information 
provided, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan 
does not have to pay for parenteral nutrition solution provided from December 19, 2019, to December 24, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography, extremities with or without related 
paraspinal areas (95864) and needle electromyography, cranial nerve supplied muscles, bilateral (95868) 
provided August 15, 2019 
 
You asked the Plan to pay for the electromyography procedures. You say that you have attached a corrected 
claim, proof and explained why each of these codes is payable. Please reprocess this corrected claim and send 
the additional payment for CPT 95961, 95962, 95868 and 95864 The Plan denied your request. The Plan says 
the records do not support the service billed. 
 
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 95864 and 95868 is not supported in the medical record. Specifically, the submitted 
medical records do not indicate that needle electromyography; cranial nerve supplied muscles, bilateral was 
performed. The submitted medical records do not indicate 4 extremities to support that needle 
electromyography, 4 extremities with or without related paraspinal areas was performed. Based on this 
information, we decided that Medicare rules for coverage of the electromyography procedures have not been 
met. Therefore, we decided that the Plan does not have to pay for needle electromyography, extremities with or 
without related paraspinal areas (95864) and needle electromyography, cranial nerve supplied muscles, 
bilateral (95868) provided August 15, 2019
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from May 3, 2020, to 
May 31, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled 
Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from January 1, 2020, 
to May 2, 2020. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing services provided from May 3, 2020, to May 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a non-
participating provider on February 18, 2020, to April 29, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you think it is unfair you are 
being charged $40 just to have your medication refilled. The Plan denied your request. The Plan says the 
correct copayments have 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 $40 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $40 copayment for each specialist telehealth services. The total amount you are 
being asked to pay is $120 ($40 x 3 = $120). Specialist services fall within the physician/practitioner 
services/specialist 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 specialist services 
provided by a non-participating provider on February 18, 2020, to April 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retainer crown for tooth #4 provided on July 23, 2019. 
 
You asked the Plan to pay for the retainer crown for tooth #4. You say that you are being charged for a 
reoccurring crown. You say that the doctor removed the crown because it was infected and replaced it with a 
bridge. The Plan denied your request. The Plan says the benefit for this service are limited to one time per 
sixty-month period. 
 
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 
one single tooth restoration every 60 months. The Plan paid for a crown for tooth #4 provided on September 
12, 2018, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the 
retainer crown for tooth #4 provided on July 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on April 10, 
2020. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that this was an emergency 
service. You also say that it is not fair that your plan does not cover benefits in full. The Plan denied your 
request. The Plan says intraoral x-rays are covered to the limit of one procedure per calendar 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, intraoral x-rays are limited to one 
procedure per calendar year. The records show that you received a first intraoral periapical x-ray on April 10, 
2020, and your intraoral x-rays benefit was then exhausted. Therefore, we decided that the Plan does not have 
to pay for the additional intraoral periapical x-ray provided on April 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0425, A0427) provided February 15, 
2020. 
 
You asked the Plan to pay for the ambulance services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the record does not support the CPT code billed. 
 
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 A0427 is not supported in the medical record. Specifically, the record shows that the 
claim is a duplicate of an already paid claim. There was no modifier to denote a repeat service. Based on this 
information, we decided that Medicare rules for coverage of the ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance services (A0425, A0427) provided 
February 15, 2020.