Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran observation stay provided from November 29, 2019, to December 1, 2019.You asked the Plan to waive the copayment foran observation stay. You say that the hospital did not perform an ultrasound, which would have shown that you blood clots.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 $400 copayment for observation stays. You have been asked to pay a $400 copayment for an observation stay. An observation stay falls within the outpatient hospital 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 foran observation stay provided from November 29, 2019, to December 1, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99343) rendered by the out of network 
(OON) provider on October 26, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the home visit (99343) rendered by the out of network (OON) provider on October 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist hand orthosis (L3908 RT) rendered by the out of 
network (OON) provider on October 14, 2019. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the item was rendered by an out of network provider, 
without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no 
exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to 
pay for the wrist hand orthosis (L3908 RT) rendered by the out of network (OON) provider on October 14, 
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on May 6, 2020. 
 
You asked the Plan to waive the coinsurance for DME. You say that 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 DME and related supplies.  
 
You received DME on May 6, 2020. The total allowed amount is 222.77 and 20% of that is $44.55. 
 
You have been asked to pay the total coinsurance amount of $44.55 for DME. DME falls within the DME and 
related 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 coinsurance for DME provided on May 6, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) and the extraction (D7140) 
provided on June 9, 2020. 
 
You asked the Plan to pay for the dental services. You say that your plan covers exams, cleanings and x-rays. 
You also say that the x-ray that you received was routine. The Plan denied your request. The Plan says the 
panoramic x-ray is not listed as a covered service. The Plan also says that the extraction is not listed as a 
covered service either. 
 
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 dental services you received are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
panoramic x-ray (D0330) and the extraction (D7140) provided on June 9, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient behavioral health services provided on August 6, 
2019, by a non-Medicare provider. 
 
You asked the Plan to pay for outpatient behavioral health services. You say that you and the enrollee 
contracted the Plan and were advised that the provider could submit claims to the Plan and that they would be 
paid. The Plan denied your request. The Plan says this provider type is not eligible in the Medicare program. 
The Health Plan has partially overturned and reprocessed with enrollee $40.00 copayment responsibility 
applied for dates of service August 19, 2019; August 26, 2019 and September 3, 2019. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of outpatient behavioral health services have not been met. The 
Health Plan reviewed all of the recorded telephone calls on the enrollee's account. The provider did not contact 
Health Plan until August 19, 2019. There are no calls prior to the first date of service, August 6, 2019 in which 
the provider was given misinformation. You are aware that as a licensed mental health counselor and licensed 
marriage and family counselor that you are ineligible to participate in the Medicare program. Based on the 
information that was provided on August 19, 2019, the Health Plan has overturned the denials for services that 
occurred after the provider's phone call. However, we are upholding the denial of payment for the August 6, 
2019 date of service as no misinformation was provided to the non-contracted provider prior to this date of 
service. Therefore, we decided that the Plan does not have to pay for outpatient behavioral health services 
provided on August 6, 2019, by a non-Medicare provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 12, 2020. 
 
You asked the Plan to pay for the testing services. You say that the ordering physician attested to the Medicare 
coverage criteria. The Plan denied your request. The Plan says coverage of comprehensive genomic profile 
testing is limited to one test per specimen. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the testing services were not billed with the most comprehensive code. 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 Guardant360 testing provided on May 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 87506) provided on September 13, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are non-
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that one of the diagnosis codes listed in LCA A56637 
must be on the claim to bill for 87506. 
 
We looked at the file and Medicare rules. CPT code 87506 was not billed with appropriate diagnosis code as 
outlined in applicable Local Coverage Article. 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 the 
services (CPT 87506) provided on September 13, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
March 4, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says payment is not allowed for this service because 
the HIPPS code submitted is invalid. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim 
was not submitted with a valid HIPPS code. Therefore, we decided that the Plan does not have to pay for the 
home health services provided to the enrollee from March 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 24, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the code is incorrectly cross-walked. The Plan 
denied your request. The Plan says there is no network deficiency 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the lab 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 lab services provided on February 24, 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 the office visit (99213) rendered by the out of network 
(OON) provider on April 15, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the office visit (99213) rendered by the out of network (OON) provider on April 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora wheelchair (K0003) purchased on May 20, 2020.You asked the Plan to pay fora wheelchair. You say that you doctor says you need this item.The Plan denied your request. The Plan says this item was not purchased from a provider that participates in Medicare.The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.We looked at the file and Medicare rules. The provider you purchased this item from is not enrolled in the Medicare program. Based on this information, we decided that Medicare rules for coverage of a wheelchair have not been met.Therefore, we decided that the Plan does not have to pay fora wheelchair (K0003) purchased on May 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy rendered from April 13, 2020, to May 11, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy rendered from April 13, 2020, to May 11, 2020.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on September 12, 2019. 
 
You asked the Plan to pay for lab tests. You say that you are requesting payment. The Plan denied your request. 
The Plan says the denial of payment for these services is correct, because the documentation does not support 
the claim as it has been billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken 
in an office setting, therefore the Place of Service (POS) code 81 indicating an independent laboratory setting  is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of 
lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing 
provided on September 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
bitewing x-ray (D0270) provided on May 27, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and bitewing x-ray. You say that 
these services were due to an emergency. The Plan denied your request. The Plan says these services exceed 
the frequency limitation in your benefit 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, problem focused limited oral 
evaluation (D0140) and bitewing x-ray (D0270) are each limited to one procedure per plan year. The record 
shows that you received a problem focused limited oral evaluation (D0140) and bitewing x-ray (D0270) on 
January 9, 2020 and your problem focused limited oral evaluation (D0140) and bitewing x-ray (D0270) 
benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused 
limited oral evaluation (D0140) and bitewing x-ray (D0270) provided on May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the abdomen (76700) rendered by the out 
of network (OON) provider on February 12, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the ultrasound of the abdomen (76700) rendered by the out of network (OON) provider on 
February 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglass lens, polycarbonate provided on June 3, 2020. 
 
You asked the Plan to pay for the eyeglass lens, eyeglass lens, polycarbonate. The Plan denied your request. 
The Plan says polycarbonate lenses are not a covered benefit. 
 
The Plan follows Medicare rules. Medicare says the use of polycarbonate or similar material will be denied as a 
non-covered deluxe feature. 
 
We looked at the file, the Plan's rules and Medicare rules. The file shows that the Plan does not cover 
polycarbonate lenses. Medicare says that the use of polycarbonate will be denied as a non-covered deluxe 
feature. Therefore, we decided that the Plan does not have to pay for eyeglass lens, polycarbonate provided on 
June 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on May 20, 2020.

You asked the Plan to waive the copayment for these services. You say that you should not be charged this amount. The Plan denied your request. The Plan says the copayment was 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 a $350 copayment for same day outpatient surgery at an outpatient hospital facility. 

Review of the file shows that you received an endoscopy on May 20, 2020. You have been asked to pay a $350 copayment for these services. These services fall within the same day outpatient surgery at an outpatient hospital facility 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 outpatient surgical services rendered on May 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 27, 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 Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 unit) remains not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

We find that HCPCS code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services provided to the enrollee on April 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interrogation device evaluations (93297) provided on 
February 9, 2020. 
 
You asked the Plan to pay for the interrogation device evaluations. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says Per NCCI PTP Coding Edits, 
Code 93297 is a component of column 1 code 93296 and 93295. 
 
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 
interrogation device evaluations has a bundled relationship with codes 93296 and 93295 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 interrogation device 
evaluations (93297) provided on February 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the enrollee for the medical services provided from 
August 21, 2019, to August 26, 2019 by an out of network provider. 
 
You asked the Plan to reimburse the enrollee for the medical services. You say that the Plan would not provide 
the services so the enrollee went out-of-network. The Plan denied your request. The Plan says there was no 
authorization for the elective 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 reimburse the enrollee 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 service at issue. 
We found no exception that would require the Plan to reimburse the enrollee for these services. Therefore, we 
decided that the Plan does not have to reimburse the enrollee for the medical services provided from August 21, 
2019, to August 26, 2019 by an out of network provider.