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

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation service 
(A0429) provided on May 22, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $265 
copayment for each covered, one-way ambulance trip by ground or water.  
 
You have been asked to pay a $265 copayment for the one-way ground ambulance trip provided. 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 ambulance transportation service (A0429) provided on May 22, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic mammogram provided by a 
participating provider on May 27, 2020. 
 
You asked the Plan to waive the copayment for diagnostic mammogram. You say that you were told that there 
would be no cost to you. 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 $100 
copayment for outpatient diagnostic tests/in-network/diagnostic test/outpatient hospital facility.  
 
You have been asked to pay a $100 copayment for diagnostic mammogram. The correct copayment has been 
applied to the diagnostic mammogram that was provided. Diagnostic mammogram falls within the outpatient 
diagnostic tests/in-network/diagnostic test/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 diagnostic mammogram provided by a participating provider on May 
27, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office or other outpatient visit provided on March 10, 2020. 
 
You asked the Plan to pay for office or other outpatient visit for the evaluation and management of an 
established patient (99212). You say that the Plan should pay this claim. The Plan denied your request. The 
Plan says place of service 23, Emergency Room-Hospital cannot be billed with an office/outpatient visit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate Place of Service code. 
 
We find that Place of Service code 23 is not correct.  Based on this information, we decided that Medicare rules 
for coverage of office or other outpatient visit for the evaluation and management of an established patient 
(99212) have not been met. Therefore, we decided that the Plan does not have to pay for office or other 
outpatient visit provided on March 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on 
March 23, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. 
The Plan denied your request. The Plan says the services are not supported by the records. 
 
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. Healthcare Common Procedure 
Coding System (HCPCS) code L0650-CG (1 Unit) remains not supported. The documentation submitted did 
not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the 
billed date of service. Therefore, the billed supply code cannot be verified. It is noted that multiple attempts 
were made to contact the provider for additional information. Therefore, we decided that the Plan does not have 
to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on March 23, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for needle electromyography; limited study of muscles in 1 extremity or 
non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, 
or sphincters (CPT Code 95870) and neuromuscular junction testing (repetitive stimulation, paired stimuli), 
each nerve, any 1 method (CPT Code 95937) provided on February 21, 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 that the services are not supported by the records. 
 
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 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 services. Our physician reviewer found 
the enclosed records and explanation sufficiently justify this code for this procedure. Patient with severe spine 
pathology and testing done due to high risk for surgical intervention. The records and explanation are 
sufficient. The medical records support the codes and billing. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or 
bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters (CPT Code 95870) and 
neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method (CPT Code 
95937) provided on February 21, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services that you provided on January 8, 2020. 
 
You asked the Plan to pay for the wound care services. The Plan denied your request. The Plan says that these 
wound care visits were for services that were foreseen, not urgent or emergent, available in area and not prior 
authorized. 
 
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 
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 wound care services that you provided on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on January 21, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 physician services provided on January 21, 
2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a back brace (L0650) provided on March 28, 2020. 
 
You asked the Plan to pay for a back brace. You say that this was medically necessary. The Plan denied your 
request. The Plan says a valid proof of delivery was not submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
proof of delivery in the file shows a delivery date of March 27, 2020. This item was billed with a date of 
service of March 28, 2020, which is neither the shipping nor delivery date. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a back brace (L0650) provided on March 28, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient colonoscopy and upper GI endoscopy provided 
on December 9, 2019. 
 
You asked the Plan to pay for the outpatient colonoscopy and upper GI endoscopy. The Plan denied your 
request. The Plan says with limited exceptions, the enrollee must use network providers to receive coverage for 
medical care and 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 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 an outpatient colonoscopy and upper GI endoscopy provided on 
December 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination provided on March 16, 2020. 
 
You asked the Plan to pay for the radiologic examination. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
radiologic examination. 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 a radiologic examination provided on March 16, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360? molecular pathology genomic profiling 
provided to the enrollee on April 19, 2020. 
 
You asked the Plan to pay for the testing. 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 rectal 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 testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Guardant360? molecular pathology genomic profiling provided to the enrollee on April 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9502) provided on February 29, 
2020 through March 13, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because 
this provider is in-network with the Plan. The Plan denied your request. The Plan says CPT code S9502 has a 
status code of I which is not valid for Medicare purposes. 
 
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 S9502 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9502 has a status indicator of I. This means that CPT code S9502 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9502) 
provided on February 29, 2020 through March 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening mammography (77067) provided on December 
5, 2017. 
 
You asked the Plan to pay for the screening mammography. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says CPT code 77067 has a status indicator 
of I and is not valid for Medicare purposes. 
 
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 77067 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 77067 had a status indicator of I on the billed date of service. This means that CPT code 77067 was not 
valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the 
screening mammography have not been met. Therefore, we decided that the Plan does not have to pay for the 
screening mammography (77067) provided on December 5, 2017.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a back brace (L0650), knee braces (L1851), and suspension sleeves 
(L2397) provided on January 24, 2020. 
 
You asked the Plan to pay for a back brace, knee braces, and suspension sleeves. You say that these items are 
supported by the submitted records. The Plan denied your request. The Plan says that the Delivery Ticket 
submitted did not include the carrier's tracking number, nor did the Proof of Delivery include an order number 
or details to corroborate the Delivery Ticket submitted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that these items were denied due to the Delivery Ticket not 
including the carrier's tracking number. However, the Delivery Ticket/invoice in the file includes a tracking 
number that matches the tracking number on the proof of delivery. The Plan has not provided information 
detailing why this is otherwise invalid. Therefore, we decided that the Plan has to pay for a back brace (L0650), 
knee braces (L1851), and suspension sleeves (L2397) provided on January 24, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visits with an orthopedist and x-
rays you received from January 28, 2020 through April 10, 2020. 
 
You asked the Plan to waive the copayments for the office visits and x-rays. You say that you thought you only 
had to pay $50 for specialist services. The Plan denied your request. The Plan says you were charged these 
copayments 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 $35 
copayment for x-ray services as well as a $45 copayment for each specialist office visit.  
 
Records show that you had multiple visits with your orthopedist from January 28, 2020 through April 10, 2020.  
During each visit, you received x-rays.  As a result, you have been asked to pay a $35 copayment for each date 
of service for the x-rays as well as a $45 copayment for each office visit with the orthopedist. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayments for the office visits with an orthopedist and x-rays you received from 
January 28, 2020 through April 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 and G0480 provided on 
December 2, 2019. 
 
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 billed are not supported by the documentation. 
 
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 codes 80307 and G0480 are not supported in the medical record. Specifically, the submitted 
documentation does not contain sufficient detail to support the billed charged. The documentation does not 
include a detailed order for the billed services. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the drug testing coded 80307 and G0480 provided on December 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on 
February 27, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. 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 $300 
copayment for plan members for outpatient surgery at an ambulatory surgical center.  
 
Review of the file shows that you received outpatient surgical services to your nose on February 27, 2020. You 
have been asked to pay a $300 copayment for these services. These services fall within the outpatient surgery at 
an ambulatory surgical center 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 February 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered on May
21, 2020.
You asked the Plan to waive the copayment for these services. You say that you thought the services were
covered under the wellness visit. 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 $20
copayment per visit for laboratory tests.
Review of the file shows that you received laboratory services on May 21, 2020. These services fall outside of
the scope of an annual wellness visit. You have been asked to pay a $20 copayment for these services. These
services fall within the laboratory 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 copayment
for the laboratory services rendered on May 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided April 21, 2020 to April 28, 2020.

You asked the Plan to waive the copayment for inpatient hospital care. 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 $225 per day copayment for days 1-6 for Inpatient Care. 

You have been asked to pay a $225 per day copayment for days 1-6 for inpatient hospital care. 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 inpatient hospital care provided April 21, 2020 to April 28, 2020.