Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discharge services provided on May 8, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says only one 
hospital discharge day management service is payable per patient per hospital stay. 
 
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 99238 is Hospital discharge day management; 30 minutes 
or less. We looked at the file and the rules. A physician may report only one per diem E&M service on a single 
date. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the discharge services provided on May 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the optometry services (92133, 92083, 99212) provided. 
 
You asked the Plan to pay for the optometry services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not emergent or pre-authorized. Network providers 
were available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 optometry services (92133, 92083, 99212) 
provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient consultation (99254) provided on May 22, 
2020. 
 
You asked the Plan to pay for the inpatient consultation. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT code 99254 has a status indicator of I 
and is not valid for Medicare purposes. 
 
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 99254 is inpatient consultation for a new or established 
patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and 
Medical decision making of moderate complexity. Counseling and/or coordination of care with other 
physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the 
problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high 
severity. Typically, 80 minutes are spent at the bedside and on the patient's hospital floor or unit.  
 
We find that CPT code 99254 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 99254 has a status indicator of I. This means that CPT code 99254 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the inpatient consultation have not 
been met. Therefore, we decided that the Plan does not have to pay for the inpatient consultation (99254) 
provided on May 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory virus panel provided on April 24, 2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says use is restricted 
to when more limited panels would not be medically appropriate. 
 
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 87633 is Infectious agent detection by nucleic acid (DNA 
or RNA); respiratory virus, includes multiplex reverse transcription, when performed, and multiplex amplified 
probe technique, multiple types or subtypes, 12-25 targets. 
 
We find that CPT code 87633 is not supported in the medical record. The code at issue was billed with a CS 
modifier, which is used on visits related to testing for Covid-19. The medical records provided note that there is 
no evidence to suggest that this respiratory panel will detect the 2019 Novel Coronavirus. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the respiratory virus panel provided on April 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a 
covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers routine transportation up to 50 miles per one-way trip.  
 
We looked at your request, the records in the case file, and the rules. Review of the file shows that you are 
requesting a transportation trip that has a shortest distance length of 53.5 miles. This exceeds the benefit limit 
of 50 miles per one-way trip. Based on this information, we decided that the Plan?s rules for coverage of 
routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional mileage for routine transportation.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health care provided out of network on 
August 7, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid by the Plan. The Plan denied 
your request. The Plan says you did not have prior authorization for out of network care. 
 
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 outpatient mental health care 
provided out of network on August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
December 16, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee self-referred out of network without 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 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 out of network physician 
services provided to the enrollee on December 16, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the positron emission tomography provided on June 1, 2020. 
 
You asked the Plan to pay for the positron emission tomography (PET) scan. You say that the Plan should pay 
this claim.  The Plan denied your request. The Plan says the diagnosis codes submitted are not listed as 
acceptable diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate ICD-10 code. 
 
In this case we find that the diagnosis codes on the claim are not on the list of appropriate codes for the PET 
scan. Based on this information, we decided that Medicare rules for coverage of the positron emission 
tomography (PET) scan have not been met. Therefore, we decided that the Plan does not have to pay for the 
positron emission tomography provided on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient assisted living visit and related 
services (99335, G8428, G8783, G0438) provided on January 8, 2020, to January 28, 2020, by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the established patient assisted living visit. You say that the services provided 
were medically necessary. 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 established patient assisted living visit and related services (99335, 
G8428, G8783, G0438) provided on January 8, 2020, to January 28, 2020, by an out of network (OON) 
provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you need rehab. The Plan denied your request. 
The Plan says the admission is not medically necessary. 
 
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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted 
to the hospital to November 4, 2020 after a fall. You received oral medications and had stable vital signs. You 
received physical and occupational therapy in the hospital and need total assistance for bed mobility and varied 
assistance with activities of daily living. You have no skilled nursing or skilled therapy needs. You do not need 
skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary 
services on an inpatient basis at the SNF level of care. 
 
 
 
 
 
 
 
 
 
 
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 pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for renal dialysis provided from March 30, 
2020, to May 30, 2020. 
 
You asked the Plan to waive the coinsurance for renal dialysis. 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 $0 
copayment for renal dialysis for members with full Medicaid eligibility or who are exempt from cost-sharing, 
and 20% coinsurance for renal dialysis for all other members for services to treat kidney disease.  
 
You received renal dialysis from March 30, 2020, to May 30, 2020. The record shows that you are partially 
eligible for Medicaid. Therefore, you are responsible to pay $1,500, which is less than the total coinsurance 
amount.  
 
You have been asked to pay $1,500 for renal dialysis. Renal dialysis falls within the services to treat kidney 
disease 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 renal dialysis provided 
from March 30, 2020, to May 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation and report on referred slides prepared 
elsewhere services coded 88321 provided on July 8, 2020. 
 
You asked the Plan to pay for the consultation and report on referred slides prepared elsewhere services. 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 claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 88321 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the consultation and report on referred slides 
prepared elsewhere services have not been met. Therefore, we decided that the Plan does not have to pay for 
the consultation and report on referred slides prepared elsewhere services coded 88321 provided on July 8, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397, 
L2385) provided to the enrollee on April 8, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery and relevant medical records which support medical 
necessity for the supplies provided in this case. The documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. 
Therefore, the billed code cannot be verified.  The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a 
knee orthosis with suspension sleeve (L1851, L2397, L2385) provided to the enrollee on April 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiological Services with an In Network 
provider at a specialist's office on June 15, 2020. 
 
You asked the Plan to waive the copayment for radiological Services with an In Network provider at a 
specialist's office. You say that you should not be responsible for the copay. The Plan denied your request. The 
Plan says the cost share 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $45 copayment for specialist's office for Outpatient diagnostic tests and therapeutic services and 
supplies.  
 
The enrollee has been asked to pay a $45 copayment for specialist's office for radiological Services with an In 
Network provider at a specialist's office. This service falls within the Outpatient diagnostic tests and 
therapeutic services and supplies 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 radiological Services with an In Network provider at a specialist's office on June 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on 
June 18, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you were at a patient at the 
hospital. The Plan denied your request. The Plan says the copayment was 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 $275 
copayment for surgery services at an outpatient hospital.  
 
Review of the file shows that you received outpatient surgery services in the form of a breast biopsy on June 
18, 2020. You have been asked to pay a $275 copayment for these services. These services fall within the 
surgery services at an outpatient hospital 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 outpatient surgical services rendered on June 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751) and core build up (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that the requested services are not cited as 
being excluded from the coverage. You say that you got a piece of floss stuck under the cap months ago that 
could lead to an infection if it is not removed. You say that your dentist advised that you needed to floss your 
teeth. You also say that now you are being penalized for something that happened as a result of what your 
dentist told you to do. The Plan denied your request. The Plan says the crown is not listed as a covered service. 
The Plan says the core build up is not listed as a covered service either. 
 
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 services are not among 
those covered under this benefit. Although the Evidence of Coverage doesn't specifically say that crowns are 
excluded from coverage, they are not specifically listed as a covered service. Therefore, we decided that the 
Plan does not have to pre-approve a crown (D2751) and core build up (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99308) provided on June 24, 2020 by an out of network (OON) provider.

You asked the Plan to pay for nursing facility care. You say that you provided medically necessary services in good faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.

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 nursing facility care (99308) provided on June 24, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a cardiovascular risk assessment panel (81225) provided.

You asked the Plan to pay for the lab test. You say that the test was medically necessary. The Plan denied your request. The Plan says this service is non-covered.

The Plan must follow Medicare rules. Medicare rules say that all CV risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients, are not covered.

We looked at the file and Medicare rules. The CPT code at issue is not covered. Based on this information, we decided that Medicare rules for coverage of the lab test have not been met. Therefore, we decided that the Plan does not have to pay for a cardiovascular risk assessment panel (81225) provided.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance services provided on July 23, 2020, and July 24, 2020.

You asked the Plan to waive the copayments for ambulance services. You say that you disagree with the charges because you were only transported less than 10 miles each trip. 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 $200 copayment for ambulance services. 

You received ambulance services on July 23, 2020. Therefore, you are responsible to pay the $200 copayment. 

You received ambulance services on July 24, 2020. Therefore, you are responsible to pay the $200 copayment.

The total amount you owe is: $400. 

You have been asked to pay the total copayment amount of $400 for ambulance services. Ambulance services fall 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 copayments for ambulance services provided on July 23, 2020, and July 24, 2020.