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

 
We decided that the Plan does not have to pay for the anesthesia services rendered on April 20, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee underwent a lumbar 
transforaminal epidural steroid injection (TFESI) with fluoroscopic guidance under monitored anesthesia care 
(MAC) and intravenous (IV) sedation. According to the American Society of Anesthesiologists (ASA), a 
monitored anesthesia care (MAC) is a planned procedure during which the patient undergoes local anesthesia 
together with sedation and analgesia.  The review has determined that this patient does not have a diagnosis, 
condition, and/or symptoms that meet the Medicare criteria for coverage of MAC. The enrollee had no 
significant past medical history to warrant MAC. The MAC was not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the anesthesia services rendered on April 20, 2020.  
 
Local Coverage Determination (LCD) L34980 referenced by the Plan is not valid for the state in which the 
services were rendered and was not used in the MAXIMUS determination.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or 
heat exchanger (99190) provided on February 19, 2020. 
 
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. 
You say that this was a necessary service. The Plan denied your request. The Plan says payment for this service 
is included in the DRG. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule.  
 
 
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of 
C on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as 
inpatient only? and therefore must be billed as part of an inpatient admission. Therefore, we decided that the 
Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger 
(99190) provided on February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography (CPT Code 95886) and nerve 
conduction studies; 11-12 studies(CPT Code 95912) provided on  November 21, 2019. 
 
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 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 services have not been met. 
 
Current Procedural Terminology (CPT) code 95912  (1 unit) remains not supported. CPT code 95912 
represents nerve conduction studies; 11-12 studies. The submitted medical records indicate that less than 11 
studies were performed. Of note, a more appropriate CPT code 95911 should be billed for the services 
performed. Therefore, the billed service cannot be verified. It is noted that multiple attempts were made to 
contact the provider for additional information. 
 
Current Procedural Terminology (CPT) code 95886 (2 units) remains not supported. The required primary 
service code (CPT code 95912) is denied. Therefore, this service cannot be reimbursed separately. In addition, 
the submitted medical records do not include a separate description to support that needle electromyography, 
each extremity, with related paraspinal areas, done with nerve conduction, amplitude and latency/velocity 
study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels 
was performed. Therefore, we decided that the Plan does not have to pay for needle electromyography (CPT 
Code 95886) and nerve conduction studies; 11-12 studies(CPT Code 95912) provided on  November 21, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 22, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that testing to confirm that a urine specimen is 
unadulterated is an internal control process that is not separately reportable. 
 
We looked at the file and Medicare rules. The file shows that the tests at issue were urine specimens utilized for 
drug testing. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
October 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 9, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that your husband was treated by the fire 
department and they advised him to go to urgent care. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 9, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided on February 9, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 22, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. 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 enrollees terminal condition. 
 
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 laboratory services provided on August 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 6, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you live on a fixed income and do not have 
funds to pay this cost. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 6, 2019. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip x-ray rendered on February 12, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The plan must follow Medicare rules. The rules say that anatomical modifiers are required for procedures 
performed on different anatomical sites. 
 
We looked at the file and Medicare rules. The file shows that procedure code 73502 was billed with the -RT 
anatomical modifier. This is a unilateral procedure code; therefore, the billing of an anatomical modifier is not 
appropriate. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the hip x-ray rendered on February 12, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided from February 3, 2020 to 
February 24, 2020. 
 
You asked the Plan to pay for the outpatient services. 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 
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 outpatient services provided from February 3, 2020 to February 
24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation and intraoral x-ray 
provided on February 20, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation and intraoral x-ray. You say that you were 
informed since the dentist was in-network everything would be covered. You say that you should be 
reimbursed. The Plan denied your request. The Plan says out-of-network dental services are not a covered 
benefit. 
 
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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation and intraoral x-ray provided on February 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 23, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you thought these services would be covered 
even though the provider is out-of-network. The Plan denied your request. The Plan says unauthorized, non-
plan care is not covered 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on September 23, 
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 30, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at 
issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the medical services provided on December 30, 2019 by an out 
of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) you received 
on April 7, 2020. 
 
You asked the Plan to waive the copayment for the EKG. You say that you do not pay for any health services, 
that your health insurance should pay for this. You say you should only have to pay your specialist copayment. 
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 $20 
copayment for non-radiologic diagnostic testing.  
 
You have been asked to pay a $20 copayment for the EKG, which is a non-radiologic diagnostic test. 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 electrocardiogram (EKG) you received on April 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Positron Emission Tomography (PET) scan provided on 
December 17, 2019. 
 
You asked the Plan to pay for PET scan. You say that according to Medicare standards this procedure code and 
diagnosis code combination have no policy and therefore are considered medically necessary. The Plan denied 
your request. The Plan says the denial of payment for this service is correct, because this service is not covered 
for the diagnosis code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are only covered when billed with 
certain specific diagnosis codes. Diagnosis code C71.9 is not among those for which a PET scan is covered by 
Medicare. 
 
We looked at the file and Medicare rules. The diagnosis code billed is not a covered diagnosis code for this 
procedure, based on Medicare billing and coding guidelines. Based on this information, we decided that 
Medicare rules for coverage of PET scan have not been met. Therefore, we decided that the Plan does not have 
to pay for a Positron Emission Tomography (PET) scan provided on December 17, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for lab work provided by a participating 
provider on March 10, 2020. 
 
You asked the Plan to waive the coinsurance for lab work. You say that you think you are being overcharged. 
The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for outpatient diagnostic tests/laboratory tests.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for lab work. The total allowed amount 
is $51.15. The total amount you are being asked to pay is $10.23 ($51.15 x 20% = $10.23). The correct 
coinsurance has been applied to the lab work that was provided. Lab work falls within the outpatient diagnostic 
tests/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 coinsurance for lab work provided 
by a participating provider on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on October 9, 2019. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT 
code 81479 for date of service October 9, 2019.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
Guardant360 testing provided on October 9, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive drug testing rendered on January 9, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive drug 
testing rendered on January 9, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 28, 2020 to 
March 2, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that the enrollee could have been treated in observation. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the records show that the enrollee presented with dysuria, hesitancy, fever, chills and urinary 
incontinence. The member was treated with antibiotics and was admitted with a diagnosis of a urinary tract 
infection. His condition stabilized and improved with medical treatment and he was discharged home when 
considered medically stable. The review indicates that the record showed that at the time of inpatient admission 
the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED 
and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from February 28, 2020 to March 2, 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 physician services provided on February 6, 2020 to March 
23, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the facility is also out-of-network. 
 
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 
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 physician services provided on February 6, 2020 
to March 23, 2020 by an out of network (OON) provider.