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

 
We decided that the Plan does not have to pay for sedation services (99152) provided on March 20, 2020. 
 
You asked the Plan to pay for sedation services. You say that the records support this code. The Plan denied 
your request. The Plan says this code is 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 code 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not document 
the presence of an independent trained observer. Based on this information, we decided that Medicare rules for 
coverage of sedation services have not been met. Therefore, we decided that the Plan does not have to pay for 
sedation services (99152) provided on March 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on May 19, 2020, to May 22, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you did not like the way 
you were treated. 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 $385 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay less than a $385 copayment per day for days 1-3 for an inpatient hospital stay. You 
have been asked to pay a total of $1,075.76 which is less than the total copayment amount of $1,155 ($385 x 3 
days = $1,155). 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 provided by a participating provider on 
May 19, 2020, to May 22, 2020.  
 
We note your complaint about not liking the way you were treated. Your complaint is a grievance that must be 
answered by the health 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 critical care services (99291) provided January 27, 2020. 
 
You asked the Plan to pay for the critical care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the services 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 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the provided records do not 
document that 30-74 minutes were spent on this service. Based on this information, we decided that Medicare 
rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not 
have to pay for critical care services (99291) provided January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection (67028, J0178) provided from  March 3, 
2020. 
 
You asked the Plan to pay for an injection. You say that this is supported in the records. The Plan denied your 
request. The Plan says these codes are not documented. 
 
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 67028 and J0178 are not supported in the medical record. Specifically, there is not a 
procedure note for the billed date of service documenting that these services were performed. Based on this 
information, we decided that Medicare rules for coverage of an injection have not been met. Therefore, we 
decided that the Plan does not have to pay for an injection (67028, J0178) provided from  March 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided 
on December 11, 2019. 
 
You asked the Plan to pay for the Comprehensive Genomic Profile (CGP) testing. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the services were 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. 
 
We find that the Comprehensive Genomic Profile (CGP) testing is not supported in the medical record. 
Specifically, this service should be billed with code 81479. In addition, the appropriate DEX Z code identifier 
should be entered adjacent to the code in the comment/narrative field. Based on this information, we decided 
that Medicare rules for coverage of the Comprehensive Genomic Profile (CGP) testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) 
testing provided on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service provided on June 5, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says additional 
payment for the service is not a covered benefit. 
 
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, we have confirmed that the code at issue has a bundled relationship with code 01610 and cannot be 
paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the special anesthesia 
service provided on June 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug test provided on July 10, 2020.You asked the Plan to pay forthe drug test. You say that the claim was separate billableidentifiable services.The Plan denied your request. The Plan says this claim is a duplicate of the claim paid on July 17, 2020.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 80305 is Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service. We find that the original claim was paid and applied to the enrollee's deductible.Based on this information, we decided that Medicare rules for coverage of the drug test have not been met.Therefore, we decided that the Plan does not have to pay forthe drug test provided on July 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for observation services provided by a 
participating provider on March 29, 2020 to April 1, 2020. 
 
You asked the Plan to waive the coinsurance for observation services. You say that you were told you were 
inpatient. You say that you were told you would owe around $1.500. 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 hospital observation.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for observation services. The total 
allowed amount is $11,065.39. The total amount you are being asked to pay is $2,213.08 ($11,065.39 x 20% = 
$2,213.08). Hospital services are considered observation services unless formally admitted as an inpatient. 
Observation services can include overnight stays. Observation services fall within the outpatient hospital 
observation 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 observation services 
provided by a participating provider on March 29, 2020 to April 1, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 7, 
2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like this claim 
reconsidered as good cause. 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 enrollee's 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 subsequent nursing facility care provided on May 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
not billed with the appropriate modifier. 
 
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 lab services in question are not supported in the medical record. Specifically, lab services were 
not reported with the appropriate modifier. Modifier -91 must be reported for repeat laboratory services. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy services provided from April 20, 2020 
to May 7, 2020. 
 
You asked the Plan to pay for home infusion therapy services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because this code is not valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code S9328 is not valid for Medicare 
purposes and is not payable.  
 
We looked at the file and Medicare rules. The billed code is not valid for Medicare purposes and is not payable. 
Based on this information, we decided that Medicare rules for coverage of home infusion therapy services have 
not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy services 
provided from April 20, 2020 to May 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breath test provided on March 17, 2020. 
 
You asked the Plan to pay for the breath test. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the above breath tests are excluded from 
coverage.  
 
We looked at the file and Medicare rules. The requested breath test for diagnosing small bowel bacterial 
overgrowth is not a covered service. Based on this information, we decided that Medicare rules for coverage of 
the breath test have not been met. Therefore, we decided that the Plan does not have to pay for the breath test 
provided on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81292, 81405, 81406, 81295, 
81298, 81317, and 81321 provided on January 10, 2020. 
 
You asked the Plan to pay for the laboratory 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 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 81292, 81405, 81406, 81295, 81298, 81317, and 81321 are not supported in the 
medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of 
the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim 
history indicates that the specimen was obtained in an office setting place of service 11. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81292, 81405, 
81406, 81295, 81298, 81317, and 81321 provided on January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring 
services coded 95940 provided on November 23, 2019. 
 
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring 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 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. 
 
In this case, the CPT Code Manual definition of code 95940 is continuous intraoperative neurophysiology 
monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List 
separately in addition to code for primary procedure). 
 
We find that CPT code 95940 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of ontinuous intraoperative neurophysiology monitoring in the operating room, 
one on one monitoring requiring personal attendance, each 15 minutes, in addition to code for primary 
procedure was performed; therefore, this code cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of the continuous intraoperative neurophysiology monitoring services have not 
been met. Therefore, we decided that the Plan does not have to pay for the continuous intraoperative 
neurophysiology monitoring services coded 95940 provided on November 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiology services provided by a 
participating provider on June 1, 2020. 
 
You asked the Plan to waive the copayment for radiology 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 $150 
copayment for outpatient diagnostic tests/radiological diagnostic service.  
 
You have been asked to pay a $150 copayment for radiology services. Radiology services falls within the 
outpatient diagnostic tests/radiological diagnostic service 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 radiology services provided by a participating provider on June 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a urinary catheter (A4352) received on 
June 17, 2020. 
 
You asked the Plan to waive the coinsurance for a urinary catheter. You say that you have never had this 
charge before. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay $534.96, or 20% of the Plan-allowed amount of $2,674.80, for a urinary catheter. 
A urinary catheter falls within the "Durable medical equipment (DME) and related 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 coinsurance for a urinary catheter (A4352) received on June 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you received. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you went to the ER but 
had to be transferred because the hospital was full of COVID-19 patients. You say that because of this, you 
shouldn't have to pay the 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 $300 
copayment for ambulance services.  
 
You have been asked to pay a $300 copayment for the ambulance services. This copayment applies regardless 
of the reason for the transport. 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 you 
received.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided, by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the laboratory 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 by the 
facility or the provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided by an out of 
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on June 22, 
2020. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you were unable to see a 
network provider due to the pandemic. The Plan denied your request. The Plan says that your plan does not 
provide coverage for additional intraoral periapical x-rays after the first intraoral periapical x-ray has been 
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. The record shows that you received a first intraoral periapical x-ray on 
June 22, 2020, which was covered by the Plan, and your intraoral x-rays benefit has been exhausted. Therefore, 
we decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on June 22, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because the 
doctor needed to check for cancer. The Plan denied your request. The Plan says these services were not pre-
approved, urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided by an out of 
network (OON) provider.