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

 
We decided that the Plan does not have to pay for testing provided on March 11, 2020. 
 
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 testing must be billed with CPT 
code 81479 for date of service March 11, 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 
testing provided on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on January 7, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for injections. You say that these services were medically necessary. You say that 
you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says 
prior authorization was not obtained for these 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 injections provided on January 7, 2020 by an out 
of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 27, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the 
Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented.   
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physicians 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 physician's services provided on February 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
June 3, 2020 to June 5, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you are unhappy with 
the care received and feel that you should not be responsible for 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 a $750 
deductible. Your contract with the Plan also clearly says that after the $750 deductible has been met, enrollee's 
must pay a $300 copayment for inpatient hospital care. 
 
You had an inpatient hospital stay from June 30, 2020 to June 5, 2020. The record shows that you had only 
paid $230.06 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay 
the remaining deductible balance of $519.94. Now that the $750 deductible has been met, you are also 
responsible to pay the $300 copayment. The total amount you owe is: $819.94.  
 
You have been asked to pay the total amount of $819.94 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 from June 3, 2020 to June 5, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a 
participating provider on May 7, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you were told that this 
would be fully covered. 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 $450 
copayment for outpatient surgery.  
 
You have been asked to pay a $450 copayment for a diagnostic colonoscopy. The colonoscopy that was 
provided was diagnostic in nature; therefore, the correct copayment has been applied. A diagnostic 
colonoscopy falls within the outpatient surgery 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 diagnostic colonoscopy provided by a participating provider on May 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99213 provided on January 31, 2020. 
 
You asked the Plan to pay for the office visit. 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. 
 
In this case, the CPT Code Manual definition of code 99213 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires at least 2 of these 3 key components: An expanded 
problem focused history; An expanded problem focused examination; Medical decision making of low 
complexity. Counseling and coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are 
spent face-to-face with the patient and/or family. 
 
We find that CPT code 99213 is not supported in the medical record. Specifically, this code was billed with 
diagnoses codes R221 (Localized swelling, mass and lump, neck), R2232 (Localized swelling, mass and lump, 
left upper limb), R2231 (Localized swelling, mass and lump, right upper limb), I10 (Essential (Primary) 
Hypertension), Z1239 (Encounter for other screening for malignant neoplasm of breast). It is inappropriate to 
report unspecified, or left and right diagnosis codes when a more specific (e.g. bilateral) code is available. 
Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. 
Therefore, we decided that the Plan does not have to pay for the office visit coded 99213 provided on January 
31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
April 21, 2020. 
 
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 April 21, 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 
comprehensive genomic profile (CGP) testing provided on April 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an excision procedure (12032, 11404) performed December 
30, 2019. 
 
You asked the Plan to pay for the procedure. You say that the services were medically necessary. The Plan 
denied your request. The Plan says surgical assistants are not eligible for reimbursement for the procedure at 
issue. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT codes 
12032 & 11404. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. 
This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be 
paid. Based upon this information, we find that Medicare coverage criteria for the procedure have not been 
met. Therefore, we decided that the Plan does not have to pay for an excision procedure (12032, 11404) 
performed December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on August 12, 2019. 
 
You asked the Plan to pay for the home visit for the evaluation and management of an established patient 
(99349). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee 
was seen in the home for an RN home care visit. 
 
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 99349 is not supported in the medical record. Specifically, there is no documentation 
that a physician was present during the home visit. Based on this information, we decided that Medicare rules 
for coverage of the home visit for the evaluation and management of an established patient (99349) have not 
been met. Therefore, we decided that the Plan does not have to pay for the home visit provided on August 12, 
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coating, tint and polycarbonate lenses. 
 
You asked the Plan to pay for the anti-reflective coating, tint and polycarbonate lenses. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are 
not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are documented as medically necessary. 
 
We looked at the file and the Plan's rules. Review of the file does not support that the medical records have 
mention of the need for the tint, anti-reflective coating, or the polycarbonate lenses. Based on this information, 
we decided that the Plan's rules for coverage of the anti-reflective coating, tint and polycarbonate lenses have 
not been met. Therefore, we decided that the Plan does not have to pay for the anti-reflective coating, tint and 
polycarbonate lenses.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered ambulance mileage provided on March 31, 
2020. 
 
You asked the Plan to pay for the non-covered ambulance mileage. You say that you needed to be transferred 
so you chose the hospital that your primary care physician is at. The Plan denied your request. The Plan says 
you were not transported to the nearest appropriate facility therefore the excess mileage is not payable. 
 
Medicare pays for the mileage to be the nearest institution with appropriate facilities. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the excess ambulance mileage have not been met. Therefore, we decided that the Plan does not 
have to pay for the non-covered ambulance mileage provided on March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Prolonged evaluation and management service before and/or 
after direct patient care, first hour (99358) provided April 22, 2020. 
 
You asked the Plan to pay for prolonged evaluation and management services. You say that please see enclosed 
medical records that support the services billed and reconsider the denial. The Plan denied your request. The 
Plan says a corrected claim may be submitted with the appropriate code to report the service performed. 
 
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 99358 is Prolonged evaluation and management (E/M) 
service before and/or after direct patient care, first hour). We find that CPT code 99358 is not supported in the 
medical record. Specifically, it is not appropriate to use CPT code 99358 when it is not related to a face to face 
service, either before or after the date the prolonged service is performed. Based on this information, we 
decided that Medicare rules for coverage of prolonged evaluation and management services have not been met. 
Therefore, we decided that the Plan does not have to pay for Prolonged evaluation and management service 
before and/or after direct patient care, first hour (99358) provided April 22, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement provided on April 20, 2020. 
 
You asked the Plan to pay for the debridement. You say that the services were medically necessary. The Plan 
denied your request. The Plan says when the enrollee elects hospice, Original Medicare takes effect on that 
day, and all services after that date should be billed to Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 17, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the debridement 
provided on April 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services received from an out-of-network provider 
on March 5, 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 services were obtained out-of-network with a 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 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 laboratory services received from an out-of-
network provider on March 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular urinary tract infection testing provided on May 
4, 2020. 
 
You asked the Plan to pay for the testing services. You say that the benefit of the test is that the results are 
available within 24 hours, as opposed to 3-4 days. The Plan denied your request. The Plan says the clinical 
value of the testing in the setting of urinary tract infections remain unproven in medical literature. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the 
documentation in the beneficiary's medical documentation 
 
We looked at the file and Medicare rules. The lab documentation shows that the results are not intended to be 
used as the sole means for clinical diagnosis or management decisions. There are insufficient medical records 
to show that the results of the testing will be used to determine a specific diagnosis or treatment strategy. 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 molecular urinary tract infection testing provided on May 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on April 21, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the OON drug testing. You say that you were not aware of prior authorization 
requirements when the services were rendered and provided this medically necessary care in good faith with 
expectation of payment. The Plan denied your request. The Plan says this enrollee's plan only covers OON care 
in emergencies or when prior authorization is obtained due to a lack of network providers. This testing was 
available from network providers. 
 
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 services provided on April 21, 
2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 5, 2020. 
 
You asked the Plan to pay for the medical services. You say that it is difficult for physicians who visit a facility 
to get authorization to provide care. The Plan denied your request. The Plan says unauthorized, non-plan care is 
not covered by the plan. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the medical services provided on March 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite provided on June 8, 2020. 
 
You asked the Plan to pay for the resin-based composite. You say that you are having difficulty eating, and are 
in pain. The Plan denied your request. The Plan says this procedure is not covered by your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-
based composite provided on June 8, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home evaluation and management (EM) services billed 
with code 99350 for date of service July 22, 2019. 
 
You asked the Plan to pay for the billed EM services. You say that this should be paid as the service was 
medically necessary. The Plan denied your request. The Plan says a physician cannot bill and be paid for EM 
services when the service was provided by a home health aide. 
 
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 99350 is Home visit for the evaluation and management 
of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval 
history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling 
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the 
presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a 
significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face 
with the patient and/or family. 
 
We find that CPT code 99350 is not supported in the medical record. Specifically, there is no evidence that the 
billing physician was face-to-face with the enrollee at any time on the date of service. This code is for 
physician services and cannot be used to bill for home health aide services. Based on this information, we 
decided that Medicare rules for coverage of the billed EM services have not been met. Therefore, we decided 
that the Plan does not have to pay for the home evaluation and management (EM) services billed with code 
99350 for date of service July 22, 2019.