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

 
We decided that the Plan does not have to waive the deductible for office visits and laboratory testing provided 
from January 10, 2019 to March 14, 2019. 
 
You asked the Plan to waive the deductible for office visits and lab tests. You say that your copayment was $35 
or $40, and you were never told this provider was not covered. The Plan denied your request. The Plan says the 
deductible amounts you are being charged are correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 deductible for out-of-network office visits and lab tests. At the 
time these claims were processed, $0 of the $500 out-of-network deductible had been met. The allowed 
amounts of these claims total $379.06, resulting in a deductible obligation of $379.06. 
 
The items or services you asked the Plan to waive the deductible for fall within the benefit categories 
"Physician/Practitioner Services, Including Doctor's Office Visits" and "Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies". The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is $500 deductible for out-of-network office visits and lab tests. This cost sharing is a contractual 
obligation that had not been met at the time office visits and lab tests was received on January 10, 2019 to 
March 14, 2019. Therefore, we decided that the Plan does not have to waive the deductible for office visits and 
laboratory testing provided from January 10, 2019 to March 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond of a crown provided on March 3, 
2020 by an OON provider. 
 
You asked the Plan to pay for the re-cement or re-bond of a crown. You say that the Plan should pay at least 
half of your bill, based on the Plan benefits. The Plan denied your request. The Plan says the treating provider 
does not have a contract with the Plan as a participating provider. The Plan also says that the treating provider 
is allowed to bill the difference of the billed amount and allowed amount. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
covered when they are received OON. The contract clearly states that you may pay more when you services are 
rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the re-cement or 
re-bond of a crown provided on March 3, 2020 by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the home health aide services (S9122) provided January 26, 2020 to February 8, 2020.
You asked the Plan to issue reimbursement for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were provided by an out of network provider that is not certified by 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. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, the services were rendered by a provider that does not participate in the Medicare program. Therefore, we decided that the Plan does not have to issue reimbursement for the home health aide services (S9122) provided January 26, 2020 to February 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on April 15, 2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically 
necessary. The Plan denied your request. The Plan says there is no evidence of a relationship with the ordering 
physician as required per CMS guidelines. 
 
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 lumbar-sacral orthosis (L0650). Our 
reviewer says that the orthosis was not medically necessary. Our physician reviewer found the enrollee was 
with diagnosed lumbar spondylosis without myelopathy or radiculopathy, low back pain, and generalized 
muscle weakness. The enrollee reports low back pain for the past eight months, intermittent and not sufficiently 
alleviated by heat, ice, or rest. There was no physical examination documented showing weakness or deformity 
of the lower back. The documentation also does not describe whether or not it is worsening or improving or 
whether physical therapy had helped. There was no information suggesting a recent injury or surgery to the 
lower back, and there was no mention of the degree of functional limitation. A request for lumbar-sacral 
orthosis (L0650) was made. Based on the limited documentation, lack of physical examination, or complete 
history, a back brace is not supported. Therefore, the criteria for such was not met. 
 
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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided 
that the Plan does not have to pay for the lumbar-sacral orthosis provided on April 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Computed Tomography (CT) of the chest (71275) provided 
February 6, 2019. 
 
You asked the Plan to pay for the CT scan. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim is a duplicate. 
 
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 71275 is not supported in the medical record. Specifically, records only support that 
one interpretation of the CT scan was performed. A previous claim was already paid for the same service on 
the same date. Based on this information, we decided that Medicare rules for coverage of the CT scan have not 
been met. Therefore, we decided that the Plan does not have to pay for Computed Tomography (CT) of the 
chest (71275) provided February 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the specialist services provided on March 19, 2020.
You asked the Plan to waive the copay for the specialist services. You say that you did not pay copays last year for this service. The Plan denied your request. The Plan says the claim was 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 $20 copay per visit to a specialist for physician services. You have been asked to pay a $20 copay for the specialist services. The services fall within the physician 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 copay for the specialist services provided on March 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on February 19, 2020. 
 
You asked the Plan to pay for the wound care supplies. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for 
inpatient services. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF to be a home. The rules say that 
Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to an 
enrollee. 
 
Records show that the wound care supplies were used in a SNF. The facility must furnish all necessary covered 
supplies to the beneficiary either directly or under arrangements made with outside providers. Theses supplies 
would have been included in the global payment submitted to the plan by the facility. If the health plan is not 
covering the SNF stay, the cost of these supplies is absorbed by the facility. Payment for this claim must be 
submitted to the facility for payment, not the health plan.  
 
Therefore, we decided that the Plan does not have to pay for the wound care supplies provided on February 19, 
2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services (CPT 99214) provided to the enrollee on February 11, 2020.
You asked the Plan to pay for the services. You say that you understand the diagnosis is causing the claim delay. The Plan denied your request. The Plan says the E/M service cannot be considered as significant and separately identifiable from CPT 90853.
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 99214 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: A detailed history; A detailed examination; Medical decision making of moderate 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. Typically, 25 minutes are spent face-to-face with the patient and/or family." We asked our coding 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 reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the medical records provided do not include documentation to validate the the EM code 99214 was provided as a separate service from CPT 90853. In order to use a 25 modifier for service 99214, the medical records must corroborate that the service was performed separately, in addition to the billed 90853. The medical records do not validate the appropriate use of 25 modifier on 99214 on February 11, 2020. We looked at this coder's review, the file, and Medicare rules. 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 office visit services (CPT 99214) provided to the enrollee on February 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Computed Tomography (CT) scan of the brain (70551) provided on March 27, 2020.
You asked the Plan to pay for the CT scan. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not pre-authorized or emergent. There were network providers available.
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 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 pay for these services. Therefore, we decided that the Plan does not have to pay for the Computed Tomography (CT) scan of the brain (70551) provided on March 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (CPT 64624) provided to the enrollee on
February 27, 2020.
You asked the Plan to pay for the services. You say that there was no payment on this claim. The Plan denied
your request. The Plan says the surgical code was submitted by a provider with an anesthesia specialty.
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 64624 is "Destruction by neurolytic agent, genicular
nerve branches including imaging guidance, when performed."
We asked our coding 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 reviewer says that the
services at issue in this case were not supported by the medical records. Our coding reviewer found the coding
range applicable to a provider whose specialty is anesthesiology are 00100-01999.
We looked at this coder's review, the file, and Medicare rules. 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 anesthesia services (CPT 64624) provided to the enrollee on February 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the allergy injection provided on February 
27, 2020 
 
You asked the Plan to waive the copayment for the allergy injection. You say that you have not been charged a 
copayment for allergy shots prior to 2020. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing 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 $20 
copayment per visit to a specialist. For this date of service, you have been asked to pay the allowed amount of 
the claim because this amount is less than the $20 copayment for the allergy injection. 
 
You have been asked to pay a $10.36 copayment for the allergy injection. The allergy injection falls within the 
?Physician/Practitioner services, including doctor?s office visits? benefit category. The record shows that the 
allergy injection is considered a physician service. 
 
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 allergy injection provided on February 27, 2020. 
 
Our decision is only about the February 27, 2020 service. If you have any questions about prior years billing, 
please contact the plan directly.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cataract surgeries provided on February 11, 2020 to February 25, 2020.
You asked the Plan to waive the copayments for the cataract surgeries. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. For each date of service, you have been asked to pay the allowed amount of the claim because these amounts are less than the $400 copayment for the cataract surgeries.
You have been asked to pay a $280.74 copayment for the cataract surgery on each date of service. The cataract surgeries fall within the "Outpatient Surgery and Other Medical Services at 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 copayments for the cataract surgeries provided on February 11, 2020 to February 25, 2020.
Your complaint about the defective product 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bupivicaine hydrochloride injection services coded 
S0020 provided on January 8, 2020. 
 
You asked the Plan to pay for the bupivicaine hydrochloride injection 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. 
 
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 S0020 is Injection, bupivicaine hydrochloride, 30 ml. 
 
We find that CPT code S0020 is not supported in the medical record. Specifically, this code has a status code 
of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code 
for reporting of and payment of these services. Based on this information, we decided that Medicare rules for 
coverage of the bupivicaine hydrochloride injection services have not been met. Therefore, we decided that the 
Plan does not have to pay for the bupivicaine hydrochloride injection services coded S0020 provided on 
January 8, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing services (HCPCS G0482) provided to the enrollee on 
October 11, 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 that Healthcare Common Procedure Coding System (HCPCS) G0482 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 HCPCS code G0482 is "Drug test(s), definitive, utilizing (1) 
drug identification methods able to identify individual drugs and distinguish between structural isomers (but 
not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any 
type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods 
(e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all 
samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or 
drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations 
and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-
21 drug class(es), including metabolite(s) if performed." 
 
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 reviewers says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found the 
laboratory submitted a valid signed physician order and lab results. The records support that 15-21 drug classes 
were tested. 
 
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 
drug testing services (HCPCS G0482) provided to the enrollee on October 11, 2019.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
August 20, 2019 to September 10, 2019. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration because you 
are billing per Medicare guidelines. The Plan denied your request. The Plan says the provider needs to report 
the Q code correctly. 
 
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, the Q code 
on this claim has not been reported correctly because it has not been recorded along with the first visit reported 
on the claim. Therefore, we decided that the Plan does not have to pay for the home health services provided to 
the enrollee from August 20, 2019 to September 10, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on July 
16, 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 G0483 are not supported in the medical record. Specifically, the 
documentation submitted did not include a valid physician order/lab requisition form or medical records signed 
by the ordering physician stating exactly what tests were to be performed. 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 G0483 provided on July 16, 2019.