Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310), pulp vitality tests (D0460), cone 
beam CT capture and interpretation (D0364), and endodontic therapy (D3320) provided on March 12, 2020. 
 
You asked the Plan to pay for the consultation, pulp vitality tests, cone beam CT capture and interpretation, and 
endodontic therapy. You say that your benefits were not explained to you correctly. You also say that you feel 
these services should be covered because you have the optional rider. The Plan denied your request. The Plan 
says consultation, pulp vitality tests, and cone beam CT capture and interpretation are not covered benefits 
under your dental plan. The Plan also says that the endodontic therapy was processed according to the Plan 
benefits at 50% coinsurance. 
 
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, consultation, pulp vitality tests, and 
cone beam CT capture and interpretation are not among those covered under this benefit. The contract also says 
that you must pay a 50% coinsurance for endodontic therapy. Therefore, we decided that the Plan does not 
have to pay for the consultation (D9310), pulp vitality tests (D0460), cone beam CT capture and interpretation 
(D0364), and endodontic therapy (D3320) provided on March 12, 2020.  
 
Your complaint about your disappointment with your dental plan 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 test provided to the enrollee on December 
17, 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  
 
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 test provided to the enrollee on December 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on December 23, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on December 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a back brace (L0650) provided on December 23, 2019. 
 
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 the submitted documentation was not sufficient. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. No medical records demonstrating the need for the brace at issue 
have been submitted. Based on this information, we decided that Medicare rules for coverage of a back brace 
have not been met. Therefore, we decided that the Plan does not have to pay for a back brace (L0650) provided 
on December 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from October 30, 2019 to February 5, 2020.

You asked the Plan to pay for the HIT services. You say that these services are medically necessary and should be covered. The Plan denied your request. The Plan says the code billed is not valid for Medicare billing.

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 S9328 is not supported. This code has a status indicator of "I" in the Physician Fee Schedule, meaning it is invalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the HIT services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from October 30, 2019 to February 5, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from February 15, 2020 
to March 15, 2020. 
 
You asked the Plan to pay for the skilled nursing services. The Plan denied your request. The Plan says the 
enrollee's condition no longer required daily skilled services at an inpatient SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from February 15, 2020 to March 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 21, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the ordering 
provider's progress notes were not submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physician?s intent that the tests be performed. The documentation does not contain progress notes from the 
ordering provider. Based on this information, we decided that Medicare rules for coverage of the lab services 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on 
February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for observation services and does not have to 
waive the coinsurance for iron infusions provided from March 30, 2020 to April 17, 2020. 
 
You asked the Plan to waive the copayments for observation services and to waive the coinsurance for iron 
infusions. You say that the charges are much higher than previous iron infusions and 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 a $298 
copayment for outpatient hospital observation. Your contract with the Plan also clearly says that you must pay 
20% coinsurance for Medicare Part B prescription drugs. 
 
You received observation services on April 6, 2020. Therefore, you are responsible to pay the allowed amount 
of $175.50, which is less than the $298 copayment.  
 
You received observation services on April 17, 2020. Therefore, you are responsible to pay the allowed amount 
of $110.73, which is less than the $298 copayment. 
 
You received iron infusions from March 30, 2020 to April 17, 2020. The total allowed amount is $961.41 and 
20% of that is $192.28.  
 
The total amount you owe is: $478.51. 
 
You have been asked to pay the total amount of $478.51 for observation services and iron infusions. 
Observation services fall within the outpatient hospital observation benefit category. Iron infusions fall within 
the Medicare Part B prescription drugs 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 observation services and does not have to waive the coinsurance for iron infusions provided from March 30, 
2020 to April 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that transportation by 
stretcher in an ambulance was necessary. The Plan denied your request. The Plan says you were charged this 
cost sharing 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 $250 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $250 for this 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 ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance provided on November 1, 2019. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you only received a routine cleaning 
during this visit. The Plan denied your request. The Plan says this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance provided on November 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from October 7, 
2018 to October 10, 2018. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for inpatient hospital care.  
 
You have been asked to pay a $350 copayment for an inpatient hospital stay. An inpatient hospital stay falls 
within the inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an inpatient hospital stay from October 7, 2018 to October 10, 2018.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the imaging services rendered on April 6, 
2020. 
 
You asked the Plan to waive the deductible for these services. You say that the testing was to see if you had 
Coronavirus and you should not be responsible for the deductible. The Plan denied your request. The Plan says 
the deductible was applied correctly. 
 
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 a $250 deductible for your covered medical services.  
 
The item or service you asked the Plan to waive the deductible for falls within the diagnostic imaging benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 
deductible for your covered medical services. This cost sharing is a contractual obligation that had not been 
met at the time these services were received on April 6, 2020. Therefore, we decided that the Plan does not 
have to waive the deductible for the imaging services rendered on April 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services a participating provider 
on February 13, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you do not agree with this 
copayment. 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 $200 
copayment for ambulance services/ground trip.  
 
You have been asked to pay a $200 copayment for ambulance services. The correct copayment has been 
applied to the services that were provided. Ambulance services fall within the ambulance services/ground trip 
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 ambulance services provided a 
participating provider on February 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a synovectomy (26145) provided on December 27, 2019. 
 
You asked the Plan to pay for the synovectomy. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
the service billed. 
 
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 26145 is synovectomy, tendon sheath, radical 
(tenosynovectomy), flexor tendon, palm and/or finger, each tendon. 
 
We asked our coder 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 synovectomy. Our reviewer says that CPT code 26145 
does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records 
provided do not include documentation of a Synovectomy, tendon sheath, radical (tenosynovectomy), flexor 
tendon, palm and/or finger, each tendon being performed on the billed date of service. 
 
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 synovectomy have not been met. Therefore, we decided that the Plan does 
not have to pay for a synovectomy (26145) provided on December 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 4, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan.  
 
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 and the referring physician are not network providers with the Plan. The 
Plan did not pre-approve the physician?s services. We found no exception that would require the Plan to pay for 
these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on 
June 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from January 21, 2020 to January 24, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 copayment per day for days 1-5 for inpatient hospital care. The enrollee had an inpatient hospital stay from January 21, 2020 to January 24, 2020. Therefore, you are responsible to pay a $300 copayment for days 1-3 (January 21, 2020 to January 23, 2020). $300 (copayment) x 3 (inpatient days) = $900. The enrollee has been asked to pay the total copayment amount of $900 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay from January 21, 2020 to January 24, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the initial observation care services (99220) provided on October 15, 
2019. 
 
You asked the Plan to pay for the initial observation care services. You say that you would like reconsideration 
because the member was discharged the day before these services were rendered. The Plan denied your request. 
The Plan says that this service has been billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 99220 
 is initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key 
components: A comprehensive history; A comprehensive examination; and Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of 
high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit.  
 
We find that CPT code 99220 is supported in the record. Specifically, the documentation submitted clearly 
shows that the member was discharged the day prior to these services being rendered. The member was 
readmitted on the date of service billed so the initial observation code is appropriate. Based on this information, 
we decided that Medicare rules for coverage of the initial observation care services have been met. Therefore, 
we decided that the Plan has to pay for the initial observation care services (99220) provided on October 15, 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on April 
1, 2020. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you believe this service is 
covered. The Plan denied your request. The Plan says the copayment amount 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 $265 
copayment for ground ambulance transportation.  
 
You have been asked to pay $265 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance 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 for ambulance 
transportation provided on April 1, 2020.