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

 
We decided that the Plan does not have to pay for the ultrasound guidance (CPT 76942) provided on February 
10, 2020. 
 
You asked the Plan to pay for the ultrasound guidance. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
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 pay for the ultrasound guidance. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no medical need for the use of ultrasound for joint needle placement. It can be done 
safely by palpation and without the use of ultrasound. 
 
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 ultrasound guidance have not been met. Therefore, we decided that the Plan 
does not have to pay for the ultrasound guidance (CPT 76942) provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist services you received on 
November 19, 2019. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible 
for the copayment. 
 
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 $20 
copayment for services obtained from a specialist.  
 
Review of the file shows that you had a specialist visit on November 19, 2019. Per your contract with plan 
name, there is a $20 copayment for specialist services. This cost sharing is a contractual obligation that you 
agreed to pay when you enrolled in plan name. However, the Medicare allowed amount for these services was 
$16.11. Given that the allowed amount was less than the $20 copayment, you have been asked to pay $16.11 
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 specialist services you 
received on November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay you had from 
February 7, 2020, through February 11, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that while in the hospital 
for a pacemaker implant, the surgeon nicked your right lung.  As a result of this, you had to stay in the hospital 
three additional days.  You do not believe you should have to pay the copayment for these additional days. The 
Plan denied your request. The Plan says you were 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 a $325 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $325 copayment per day for each of the four days you were in the hospital. This 
amount applies regardless of the reason for the length of the stay. 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 you had from February 7, 2020, through February 11, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
October 27, 2019. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service October 27, 2019.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
comprehensive genomic profile (CGP) testing provided on October 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist services provided from January 
28, 2020, to April 16, 2020. 
 
You asked the Plan to waive the copayments for specialist services. You say that you disagree with the charges 
due to the service received by a physician and feel that all visits should be covered. The Plan denied your 
request. The Plan says the claims were processed correctly, and the enrollee is 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $45 copayment for specialist services. 
 
The enrollee received specialist services provided from January 28, 2020, to April 16, 2020 for a total of 3 
visits. Therefore, the enrollee is responsible to pay a $45 copayment per each visit. The total amount the 
enrollee owes is $135. 
 
The enrollee has been asked to pay the total copayment amount of $135 for specialist services. Specialist 
services fall within the physician/practitioner services, including doctor's office visits benefit category. 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 copayments for specialist services provided from January 28, 2020, to 
April 16, 2020.  
 
We note your complaint that you are unhappy with the service provided by the physician. Your complaint is a 
grievance that must be answered by the health plan. Medicare does not permit us to make a decision about 
these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the cardiovascular procedures, lipid 
panel, echocardiography, MRI and occupational therapy services provided from May 15, 2019, through May 
17, 2019. 
 
You asked the Plan to reduce the copayments for the cardiovascular procedures, lipid panel, echocardiography, 
MRI and occupational therapy services. You say that it was your understanding that you would be admitted for 
testing and treating but was put in observation at a higher cost. You say that you are on a limited budget and 
need help with the charges. The Plan denied your request. The Plan says the copayments applied 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 $285 
copayment for each surgical or observation room service you get at an outpatient hospital, a $10 copayment for 
each covered lab service from an in-network provider, a $150 copayment for covered diagnostic radiology 
services in the outpatient department of a network hospital or facility and a $40 copayment for each covered 
physical, occupational and speech therapy visit from an in-network provider. 
 
  
You have been asked to pay a total of $729.20 for the cardiovascular procedures, laboratory services, 
echocardiography, MRI and occupational therapy services. 
 
Date of Service Service Allowed 
Amount 
Standard 
Copayment 
Member Liability 
May 15, 2019 Cardiovascular Procedure $126.40 $285 $126.40 
May 16, 2019 Cardiovascular Procedure $126.40 $285 $126.40 
May 16, 2019 Lipid Panel $14.88 $10 $10 
May 16, 2019 Echocardiography $462.54 $150 $150 
May 16, 2019 MRI $505.98 $150 $150 
May 17, 2019 OT Evaluation $14.80 $40 $14.80 
May 17, 2019 Self-Care Training $25.20 $40 $25.20 
May 17, 2019 Cardiovascular Procedure $126.40 $285 $126.40 
TOTAL:    $729.20 
 
The cardiovascular procedures fall within the "Outpatient hospital services" benefit category. The lipid panel, 
echocardiography and MRI fall within the Outpatient diagnostic tests and therapeutic services and supplies 
benefit category. The self-care training and OT evaluation fall within the Outpatient rehabilitation services
benefit category. 
 
The records show that you were admitted to outpatient observation. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the 
copayments for the cardiovascular procedures, lipid panel, echocardiography, MRI and occupational therapy 
services provided from May 15, 2019, through May 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an IV tubing extension set and infection control supplies 
provided on March 9, 2020. 
 
You asked the Plan to pay for medical supplies. You say that you are appealing. The Plan denied your request. 
The Plan says the denial of payment for these items is correct, because these codes are not valid for Medicare 
purposes and are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that codes S1015 and S8301 are not valid for 
Medicare purposes and are not payable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of medical supplies have not been met. Therefore, we decided that the Plan does not have to pay for 
an IV tubing extension set and infection control supplies provided on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection of a drug into the eye (67028) 
performed at a specialist's office on March 24, 2020. 
 
You asked the Plan to waive the copayment for an injection of a drug into the eye. You say that the provider 
made an error in billing. The Plan denied your request. The Plan says the correct copayment was 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 $30 
copayment for each specialist visit for Medicare-covered benefits.  
 
You have been asked to pay a $30 copayment for an injection of a drug into the eye. An injection of a drug into 
the eye performed at a specialist's office falls 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 copayment for an injection of a drug into 
the eye (67028) performed at a specialist's office on March 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided to the enrollee on January 21, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the enrollee was inpatient at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the various denied radiology codes (CPT 88314, CPT 88350, CPT 88313, CPT 88305) are not 
supported in the medical records. These services cannot be paid separately when the enrollee is an inpatient. 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pay for radiology services provided to the enrollee on 
January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction study and needle elextromyography 
billed for services provided on October 7, 2019. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says there is 
insufficient documentation to corroborate the services. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the 
documentation in the beneficiary's medical documentation. 
 
We find that the services at issue are not supported in the medical record. Specifically, the documentation 
shows inconsistent dates for when the services were provided. There are no additional records notating or 
explaining the addendum. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for the nerve conduction study and needle 
elextromyography billed for services provided on October 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses (V2020, V2200) purchased on October 24, 2019. 
 
You asked the Plan to pay for eyeglasses. You say that this was approved by the plan. The Plan denied your 
request. The Plan says the submitted information is insufficient to support payment. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. 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 the Plan's rules. Although the Plan offers coverage for the items at issue, neither 
medical records not an itemized receipt to show the specific items that were purchased have been submitted. 
Without this documentation, these items cannot be verified. Based on this information, we decided that the 
Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to 
pay for eyeglasses (V2020, V2200) purchased on October 24, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a sleep study (95810) performed on March 17, 2020.

You asked the Plan to waive the copayment for a sleep study. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 each facility-based sleep study. 

You have been asked to pay a $40 copayment for a sleep study performed at a facility. A sleep study 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 copayment for a sleep study (95810) performed on March 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on May 27, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
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 drug testing provided on May 27, 2020 by an 
out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided from February 10, 2020, to 
February 15, 2020. 
 
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was 
stable for transfer on admission. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient care. Our reviewer says that the 
requested inpatient care was not medically reasonable and necessary. Our physician reviewer found that the 
enrollee was stable and only required antibiotics and IV fluids at the time of admission. Consultation with 
Urology and medication adjustments could have been made after transfer. There was no documentation of the 
enrollee being unstable or not able to transfer for any reason at the time of admission. Based on the provided 
documentation, the enrollee was stable enough for transfer of care on February 10, 2020, at 17:49. 
 
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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient care provided from February 10, 2020, to February 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing- four radiographic images (D0274) provided on 
June 22, 2020. 
 
You asked the Plan to pay for the bitewing- four radiographic images (D0274). You say that you have never 
had routine bitewing images denied until now. You say that bitewing images and intraoral are identical except 
for the coding. The Plan denied your request. The Plan says the service 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, the requested items or services are not 
among those covered under this benefit. Four radiographic bitewing images are not considered a complete 
series x-ray. Therefore, we decided that the Plan does not have to pay for the bitewing- four radiographic 
images (D0274) provided on June 22, 2020.  
 
Your complaint about the Plan committing fraud 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray provided to the enrollee on June 29, 2020. 
 
You asked the Plan to pay for the x-ray. You say that the service should be covered. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that examinations required by third parties such as 
insurance companies, business establishments, or Government agencies are not covered.  
 
We looked at the file and Medicare rules. The requested x-ray was provided as part of a third party requirement 
for admission to an assisted living facility. Tests required by third parties are not covered. 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 the x-ray provided to the enrollee on June 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on January 3, 2020. 
 
You asked the Plan to pay for genetic testing. You say that this testing enabled the enrollee's treating physician 
to determine the optimal treatment pathway. The Plan denied your request. The Plan says the denial of payment 
for this testing is correct, because this testing was not billed with the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT 
code 81479 for date of service January 3, 2020.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
Guardant360 testing provided on January 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hematoma drainage billed for services provided on April 18, 
2019. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
service cannot be verified. 
 
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 10140 is incision and drainage of hematoma, seroma or 
fluid collection. We find that CPT code 10140 is not supported in the medical record for the date of service at 
issue. Based on this information, we decided that Medicare rules for coverage of the services provided have not 
been met. Therefore, we decided that the Plan does not have to pay for hematoma drainage billed for services 
provided on April 18, 2019.