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

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on March 6, 
2020. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you were misled by your 
insurance agent and believe you would not be charged this much. The Plan denied your request. The Plan says 
the coinsurance you are being charged is correct. 
 
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 15% 
coinsurance for each in-network covered surgery or observation room service in an outpatient hospital.  
 
The allowed amount of the claim is $6,189.35, resulting in a coinsurance obligation of $928.40 for outpatient 
surgery performed in an outpatient hospital setting ($6,189.35 x 15% = $928.40). Outpatient surgery falls 
within the each in-network covered surgery or observation room service in an 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 outpatient surgery provided on March 6, 2020.  
 
Your complaint about being misled by your insurance agent 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Radiology services (72141) provided May 20, 2020. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim included in inappropriate place of service. 
 
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 72141 is not supported in the medical record. Specifically, the claim included an 
outpatient place of service. The record shows the enrollee was an inpatient at the time services were provided. 
Based on this information, we decided that Medicare rules for coverage of the radiology services have not been 
met. Therefore, we decided that the Plan does not have to pay for Radiology services (72141) provided May 
20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (CPT Code L0650) provided to the enrollee. on January 27, 2020.

You asked the Plan to pay for the orthosis. You say that the orthosis is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.

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 the orthosis have not been met. Review of the file shows back pain that may be improved with bracing. The record sent by you indicates the member saw the provider on January 27, 2020 at which time back pain was mentioned and your planned spine surgery however no mention is documented of the need for bracing. The received records include a prescription for this brace dated January 27, 2020 and is signed by the provider. There is no commensurate note in the medical record by the provider on or around that date as to why the braces were being ordered.

The rules say a face-to-face encounter is required with documentation that includes information supporting that the beneficiary was evaluated or treated for a condition that supports the DME item(s) ordered. If this information is not included, the contractor shall deny the claim. If the physician completed the written order before the face-to-face encounter, the contractor shall deny the claim.

Under Medicare guidelines, your request is not medically necessary because the records show you do not have an appropriate face-to-face encounter documented in the records to substantiate the need for this item. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (CPT Code L0650) provided to the enrollee. on January 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder test provided to the enrollee on March 18, 
2020. 
 
You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The 
Plan says this test was validated in a prospective multicenter clinical study and published in a peer-reviewed 
journal. 
 
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 test. Our reviewer says that the requested 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found 
Cxbladder testing has not been shown to be superior to cystoscopy, and its clinical use is not determined to be 
medically reasonable and necessary at this time. 
 
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 test have not been met. Therefore, we decided that the Plan does not have to 
pay for the CxBladder test provided to the enrollee on March 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound guided breast biopsy 
(19083) provided on April 27, 2020. 
 
You asked the Plan to waive the copayment for the biopsy. You say that this was a needle biopsy and you were 
there maybe 30 minutes. No operating room was used and no recovery required. You did not need to be put to 
sleep for this simple procedure. The Plan denied your request. The Plan says this claim was processed correctly 
and the correct copayment applied according to the plan benefits. 
 
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 $325 
copayment for surgical services in an outpatient hospital facility.  
 
You have been asked to pay $325 copayment for the biopsy. The biopsy falls within the Outpatient surgery, 
including services provided a hospital outpatient facilities and ambulatory surgical centers 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 ultrasound guided breast biopsy (19083) provided on 
April 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (CPT 99152) provided to the 
enrollee on July 18, 2019. 
 
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 Current Procedural Terminology (CPT) code 99152 (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 CPT code. 
 
In this case, the CPT Code Manual definition of code 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15minutes of intraservice time, patient age 5 
years or older." 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not indicate 
the presence of an independent trained observer. The code cannot be verified. 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 moderate sedation services (CPT 99152) provided to the enrollee on July 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided 
from April 20, 2020 to April 22, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you should only 
have an outpatient copay. The Plan denied your request. The Plan says that you received inpatient care and 
were charged the correct 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 $200 
copayment per day for days 1 through 5 of Inpatient hospital care.  
 
You have been asked to pay a $400 copayment for the inpatient hospital services. The inpatient hospital 
services fall within the days 1 through 5 of 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 the inpatient hospital services provided from April 20, 2020 to April 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings, periodic oral evaluation, prophylaxis, and 
amalgams provided on January 29, 2020 and February 3, 2020. 
 
You asked the Plan to pay for the bitewings, periodic oral evaluation, prophylaxis, and amalgams. You say that 
no dental providers were listed in the Plan's provider directory. You also say that your Annual Notice of 
Changes for 2020 states that you have a $1,000 allowance for preventive and comprehensive dental services. 
The Plan denied your request. The Plan says services from Medicare opt-out providers are not covered under 
your plan. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the bitewings, periodic oral evaluation, prophylaxis, and amalgams provided on January 29, 2020 and February 
3, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the magnetic resonance imaging (MRI) 
provided on January 8, 2020. 
 
You asked the Plan to waive the cost share for the testing services. You say that you cannot afford the copay. 
The Plan denied your request. The Plan says the claim processed 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 $300 
copay for diagnostic radiology other than CT scans.  
 
You have been asked to pay a $300 for the testing services. The services fall within the outpatient diagnostic 
tests 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 cost share for the magnetic resonance imaging 
(MRI) provided on January 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray (71046) provided April 28, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the code is not separately payable. 
 
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 71046 
has a Column I / Column II relationship with code 32555 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 a chest x-ray (71046) provided April 28, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation for use and/or fitting of voice prosthetic device to 
supplement oral speech (CPT Code 92597) provided to the enrollee on March 24, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says payment may not be made to a physical therapist, occupational therapist, or speech-
language pathologist in private practice if the service is provided in an inpatient hospital or outpatient hospital. 
 
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 the services have not been met. Payment may not be made to a 
physical therapist, occupational therapist, or speech-language pathologist in private practice if the service is 
provided in an inpatient hospital or outpatient hospital. Per review of claim summary the POT is billed for 22 
(On campus - outpatient hospital).  
Therefore, we decided that the Plan does not have to pay for evaluation for use and/or fitting of voice prosthetic 
device to supplement oral speech (CPT Code 92597) provided to the enrollee on March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 molecular pathology genomic profiling 
provided to the enrollee on April 2, 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 Medicare requires use of CPT 81479 to report a Guardant360? molecular pathology genomic 
profiling for breast cancer, 
 
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 various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 Guardant360 molecular pathology genomic profiling provided to the enrollee on April 2, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for chiropractic manipulative treatment (98942) 
performed on October 29, 2019. 
 
You asked the Plan to waive the coinsurance for chiropractic manipulative treatment. You say that you were 
told you would have no copayment for this service. The Plan denied your request. The Plan says that the 
correct coinsurance 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 does not say in clear and accurate terms 
how much you should expect to pay for Medicare-covered chiropractic services.  
 
We looked at your contract with the Plan. We did not see where the contract says under what circumstances 
enrollees must pay 20% coinsurance for Medicare-covered chiropractic services. The Plan contract states there 
is 0% coinsurance or 20% coinsurance for these services but does not specify when the 0% applies and when 
the 20% applies. The Plan contract does not clearly say how much enrollees must pay for Medicare-covered 
chiropractic services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing 
information. Therefore, we decided that the Plan has to waive the coinsurance for chiropractic manipulative 
treatment (98942) performed on October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chiropractic manipulative treatment 
(CMT); spinal, 3-4 regions (CPT Code 98941) provided on March 4, 2020 by an in-network provider. 
 
You asked the Plan to waive the copayment for the services. You say that the services were necessary due to 
your trouble breathing. The Plan denied your request. The Plan says the claim was processed accordingly with 
your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received chiropractic manipulative treatment (CMT); spinal, 3-4 regions (CPT 
Code 98941) provided on March 4, 2020 by an in-network provider. You are asked to pay a $20 copayment for 
the in-network chiropractic 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 chiropractic 
manipulative treatment (CMT); spinal, 3-4 regions (CPT Code 98941) provided on March 4, 2020 by an in-
network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 5, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary for 
this patient. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on December 5, 
2019 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 subsequent hospital care services provided on December 
16, 2019 and December 17, 2019. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care services provided on December 
16, 2019 and December 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you do not need an intensive team approach for your care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and shortness of 
breath. After evaluation and treatment, medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. The medical record supports the need 
for physical and occupational therapy but does not document a need for an intensive rehabilitation program. 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not 
meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.