Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by a participating 
provider on April 29, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that you would like reimbursement for 
these charges. 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 $30 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $30 copayment for an office visit. An office visit falls within the 
physician/practitioner services/specialist 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 office visit provided by a participating provider on April 29, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copays for the medical services provided on July 24, 2020. 
 
You asked the Plan to waive the copays for the services provided. You say that you had to return to the hospital 
after surgery. 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 $250 
copay per visit for Medicare-covered blood transfusion services.  
 
You have been asked to pay a $250 copay for the services provided. The services fall within the outpatient 
hospital services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copays for the medical services 
provided on July 24, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the colonoscopy provided on August 11, 2020. 
 
You asked the Plan to waive the copay for the services provided. You say that you had no symptoms, and 
received a screening colonoscopy. The Plan denied your request.  
 
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 $450 
copay for each visit to an ambulatory surgical center for outpatient surgery.  
 
The file shows that you received a colonoscopy with lesion removal. The removal of lesions is considered a 
surgical service. You have been asked to pay a $450 copay for the services provided. The services fall within 
the outpatient surgery 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 colonoscopy 
provided on August 11, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care services. 
 
You asked the Plan to pre-approve home health care services. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the services you are requesting are 
considered custodial care services. Custodial care services are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that custodial care is not covered. 
 
We looked the file and Medicare rules. In this case, the home health care services you are requesting are 
considered custodial care based on Medicare guidelines. Custodial care includes care that helps people with 
activities of daily living, like walking, getting in and out of bed, bathing, dressing, eating, personal hygiene, 
and supervision of special diets and medications. Custodial care is not covered under Medicare or the Plan. 
Based on this information, we decided that Medicare rules for coverage of home health care services have not 
been met. Therefore, we decided that the Plan does not have to pre-approve home health care services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Esomeprazole. 
 
You asked the Plan to pre-approve Esomeprazole (J8499). You say that you want the enrollee treated with this 
drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Esomeprazole.  
 
Benefits for Esomeprazole (J8499) may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the remote cardiovascular monitoring 
provided on June 23, 2020. 
 
You asked the Plan to waive the copayment for the remote cardiovascular monitoring. You say that you already 
paid a $30 copayment to the company that supplied the monitor. You say that you shouldn't have to pay 
another copayment for having the reading done. The Plan denied your request. The Plan says the copayment 
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 $30 
copayment for Medicare-covered non-radiological diagnostic services from an in-network provider.  
 
You have been asked to pay $25.77, which is less than the standard $30 copayment for the remote 
cardiovascular monitoring. The remote cardiovascular monitoring falls within the "Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies" benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the remote cardiovascular monitoring provided on June 23, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 19, 2020. 
 
You asked the Plan to pay for the services provided. You say that you are not associated with the hospice. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment of services. 
 
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 medical services provided on June 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive evaluation (D0150), the oral hygiene 
instructions (D1330), the gingival irrigation (D4921 x 3), the local anesthesia in conjunction with surgical 
procedures (D9215), the unspecified preventive service (D1999), and the unspecified periodontal service 
(D4999 x 3) provided on June 23, 2020. 
 
You asked the Plan to pay for the oral exam, the oral hygiene instructions, the gingival irrigation, the local 
anesthesia, the unspecified preventive service, and the unspecified periodontal service. You say that you went 
in for a routine cleaning. You say that after the exam, you were advised you needed additional services. You 
say that you were quoted $392 for the services. You say that had you known that the services would be denied, 
you would not have gotten the services. The Plan denied your request. The Plan says 1 comprehensive oral 
exam is covered every 3 plan years. The Plan says that the frequency limit for this service has been exceeded. 
The Plan also says that the oral hygiene instructions, the gingival irrigation, the local anesthesia, the 
unspecified preventive service, and the unspecified periodontal service are not listed as covered services. 
 
 
 
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 oral hygiene instructions, the 
gingival irrigation, the local anesthesia, the unspecified preventive service, and the unspecified periodontal 
service are not among those covered under this benefit. Although comprehensive evaluations are listed as a 
covered service, the frequency limit of once every 3 plan years has been exceeded. The record shows that the 
Plan paid for a comprehensive evaluation that you received on June 10, 2020. Therefore, we decided that the 
Plan does not have to pay for the comprehensive evaluation (D0150), the oral hygiene instructions (D1330), the 
gingival irrigation (D4921 x 3), the local anesthesia in conjunction with surgical procedures (D9215), the 
unspecified preventive service (D1999), and the unspecified periodontal service (D4999 x 3) provided on June 
23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (CPT 97012) received from May 29, 
2020 to June 17, 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 this is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services (CPT 97012) received from May 29, 2020 to June 17, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 9, 2020. 
 
You asked the Plan to pay for the services provided. You say that the codes are payable as billed. The Plan 
denied your request. The Plan says they were unable to determine how the enrollee came to the servicing 
provider, or whether the services are medically necessary. 
 
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 services at issue are not supported in the medical record. In this case, there is insufficient 
medical records provided to substantiate the billed codes. The documentation does show that the Plan made 
several attempts to obtain the necessary information, however, none was obtained. Based on this information, 
we decided that Medicare rules for coverage not been met. Therefore, we decided that the Plan does not have to 
pay for the lab services provided on June 9, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 23, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the enrollee was not in hospice 
at the time of service. The Plan denied your request. The Plan says Original Medicare would be responsible for 
payment of all Medicare covered services related or unrelated to the member?s terminal condition. The 
Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of 
election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers 
attending physician services and all care unrelated to the terminal illness until the first day of the month 
following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 5, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility 
care provided on July 23, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the corneal pachymetry provided on June 
18, 2020. 
 
You asked the Plan to waive the copayment for corneal pachymetry. You say that this test never happened. The 
Plan denied your request. The Plan says you were charged this copayment 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 $30 
copayment for Specialty Physician diagnostic tests.  
 
You have been asked to pay a $8.79 copayment for corneal pachymetry. This is the allowable amount for this 
procedure and less than your required copayment. Corneal pachymetry falls within the Specialty Physician 
diagnostic tests benefit category. The medical record shows pachymetry was done. 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 corneal pachymetry provided on June 18, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the digital analysis of electroencephalogram with CPT code 
95957 provided on July 8, 2020. 
 
You asked the Plan to pay for CPT code 95957. You say that the medical records support the billing of CPT 
code 95957. The Plan denied your request. The Plan says the medical records do not support the billing of CPT 
code 95957. 
 
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 95957 is Digital analysis of electroencephalogram (EEG) 
(eg, for epileptic spike analysis). 
 
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 CPT code 95957. Our reviewer says that the 
medical records do not support the billing of CPT code 95957. Our physician reviewer found in this case the 
member underwent a routine EEG. The EEG report indicated that an (automated) digital spike and wave 
analysis program was run to aid in analysis of the EEG. 
 
Guidelines from the American Clinical Neurophysiological Society have long stated: "Code 95957 should not 
be used simply when the EEG was recorded digitally. There is no additional charge for turning on an 
 
 
automated spike and seizure detector on a routine EEG, ambulatory EEG, or video EEG monitoring. Nor is 
there an additional code for performing EEG on a digital machine instead of an older generation analog 
machine." 
 
The report indicated that an automated spike detection algorithm was run. This is not the same as provision of 
formal "digital analysis" (which is a unique procedure that is more involved and requires other time and 
resources). Ultimately, it can be said that the records provided for review do not support the code submitted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPT code 95957 have not been met. Therefore, we decided that the Plan does 
not have to pay for the digital analysis of electroencephalogram with CPT code 95957 provided on July 8, 
2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided to the enrollee on June 5, 
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 the provider is not eligible. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program.  
 
You are not eligible to bill Medicare. The plan did not pre-approve the services. We found no exception that 
would require the plan to pay for these items/services. 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 emergency room services provided to the enrollee on June 5, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided daily 
skilled services are not required. You do not require the services on an inpatient basis, in a skilled nursing 
facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for refractions (92015) provided July 13, 2020. 
 
You asked the Plan to pay for the refractions. You say that the services should be covered. The Plan denied 
your request. The Plan says the refractive services are not covered under your benefit plan unless rendered by a 
Routine Vision Care provider found in the Routine Vision Care section of the plan?s provider directory. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when rendered by a Routine Vision Care provider found in the 
Routine Vision Care section of the plan?s provider directory. 
 
 
 
 
 
We looked at the file and the Plan's rules. The services were not provided by a contract provider. Based on this 
information, we decided that the Plan's rules for coverage of the refractions have not been met. Therefore, we 
decided that the Plan does not have to pay for refractions (92015) provided July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chemotherapy administration and injections provided on 
May 20, 2020. 
 
You asked the Plan to pay for the chemotherapy administration and injections. You say that the Plan should 
pay this claim. The Plan denied your request. The Plan says the services are not supported in the medical 
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 find that CPT codes 96375, 96413, 96417, J1100, J1200, J2405, J9201, J9264 are not supported in the 
medical record. Specifically, the records do not indicate that J9264, J2405, J9201, J1100, or J1200 were 
administered. The records do not indicate a start and stop time to support chemotherapy administration 96413. 
The required preceding procedure code for 96417 and 96375 was not supported so the service cannot be 
reimbursed separately. Based on this information, we decided that Medicare rules for coverage of the 
 
 
chemotherapy administration and injections have not been met. Therefore, we decided that the Plan does not 
have to pay for the chemotherapy administration and injections provided on May 20, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to hold you harmless for laboratory services (82785) provided on October 23, 
2019. 
 
You asked the Plan to hold you harmless for laboratory services. You say that you are not able to get the claim 
corrected. The Plan denied your request. The Plan says that this service cannot be paid as billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided laboratory services by a contract provider. The file does not show that the Plan provided 
notice that laboratory services would not be covered. Under Medicare rules, this means laboratory services is 
considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for laboratory 
services (82785) provided on October 23, 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.