Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the x-ray exam of the cervical spine 
(72050), x-ray exam of the thoracic spine (72070), and the x-ray exam of the shoulder (73030) provided on 
May 20, 2020. 
 
You asked the Plan to adjust the copayment for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment 
has been applied correctly to the services provided. 
 
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 $105 
copayment for basic radiological services provided at an outpatient hospital.  
 
You have been asked to pay a $105 copayment for the basic radiological services provided at an outpatient 
hospital. 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 adjust the copayment for the x-ray exam of the cervical spine (72050),  
x-ray exam of the thoracic spine (72070), and the x-ray exam of the shoulder (73030) provided on May 20, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for foot orthotics provided on March 20, 
2020. 
 
You asked the Plan to waive the coinsurance for foot orthotics. You say that you were told that this would not 
cost you anything. The Plan denied your request. The Plan says the coinsurance amount you are being charged 
is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for foot orthotics. The allowed amounts of these items total $830.27, resulting in a total 
coinsurance obligation of $166.07. 
 
You have been asked to pay 20% coinsurance for foot orthotics. Foot orthotics fall within the Prosthetic 
Devices 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 foot 
orthotics provided on March 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided by a 
participating provider on March 23, 2020 
 
You asked the Plan to waive the copayment for physical therapy. You say that all the doctor did was talk to 
you. 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 outpatient rehabilitation services.  
 
You have been asked to pay a $30 copayment for physical therapy. Physical therapy falls within the outpatient 
rehabilitation services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physical 
therapy provided by a participating provider on March 23, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shoulder orthosis (L3960) provided on April 8, 2020. 
 
You asked the Plan to pay for the orthosis. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is no evidence of a face-to-face or telehealth 
encounter. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. 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 shoulder orthosis (L3960) 
provided on April 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services by you on August 27, 2019. 
 
You asked the Plan to pay for the ambulance services. You say that you were contacted by the provider to 
transport the enrollee. 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 pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor's office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. 
Therefore, we decided that the Plan does not have to pay for the ambulance services by you on August 27, 
2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing rendered on February 11, 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 are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that BCR/ABL testing is covered for specific 
diagnoses only and that full gene sequencing should not be reported using codes that assess for the presence of 
gene variants unless the CPT code specifically states full gene sequence in the code descriptor. 
 
We looked at the file and Medicare rules. The file shows that BCR/ABL testing was performed for a diagnosis 
of C18.2 (malignant neoplasm of colon). This is not a diagnosis for which this testing is covered by Medicare. 
The file shows that the claim for these services was billed with individual codes; however, billing as one 
service under CPT 81479 is appropriate, per Medicare rules. The Plan will reprocess the claim for codes 
81161-81355 and 81400-81408 under code 81479. 
 
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 genetic testing rendered on February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided December 4, 2019 
 
You asked the Plan to pay for the acute inpatient level of care. You say that please see attached documentation 
that proved you sent medical records back in 03/27/2020 and 04/03/2020. The Plan denied your request. The 
Plan says original Medicare or previous MA organization is responsible for payment for inpatient hospital 
services, as appropriate until the date of discharge, even if it extends beyond effective date. 
 
The Plan must follow Medicare rules. Medicare rules say that the plan that covered the enrollee at the 
beginning of an inpatient stay is responsible for the entire stay. If there is a change in coverage during the stay, 
the new Plan is not responsible for inpatient hospital care until after the date of discharge.  
 
A different health plan was not the Plan of record at the time of the inpatient stay at issue in this appeal began. 
This means that the new plan is not responsible for coverage of inpatient hospital services until after this stay 
ended. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided 
December 4, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for enteral feeding supplies (B4035) provided from November 
15, 2019, to December 14, 2019. 
 
You asked the Plan to pay for enteral feeding supplies. You say that other claims for these items have been 
paid. The Plan denied your request. The Plan says a proof of delivery for these items has not been submitted. 
 
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 for the supplies provided in this case. A proof of delivery 
was not included in the submitted documentation. 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 enteral feeding supplies (B4035) provided from November 15, 2019, to December 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) 
provided on January 6, 2020. 
 
You asked the Plan to pay for the bone replacement graft. You say that your book of coverage does not say that 
the decision by the dentist and the enrollee can be over-ridden by the insurance plan. The Plan denied your 
request. The Plan says this service is not covered by your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft for ridge preservation (D7953) provided on January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services rendered on May 4, 2020 to 
May 6, 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. The file shows that the billed services have a status indicator of E for 
non-covered services when billed with revenue code 0637 without a HCPCS code. 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 outpatient hospital services rendered on May 4, 2020 to May 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient surgery provided by a 
participating provider on February 3, 2020. 
 
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you are not sure if you 
should be getting charged two coinsurances. The Plan denied your request. The Plan says the correct 
coinsurances have 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% 
coinsurance for outpatient surgery/in-network/outpatient hospital.  
 
You have been asked to pay a 30% coinsurance of the allowed amount for an outpatient surgery. The total 
allow amount is $3,296.97. The total amount you are being asked to pay is $989.09 ($3,296.97 x 30% = 
$989.09). An outpatient surgery falls within the outpatient surgery/in-network/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 coinsurance for outpatient surgery provided by a participating 
provider on February 3, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you disagree with the charges because 
you were told that you would not owe anything. 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 days 1-20 and a $160 copayment for days 21-100 for SNF care.  
 
You had a SNF stay. You are not being charged a copayment for days 1-20 
(May 11, 2020 to May 30, 2020). You are responsible to pay a $160 (copayment) for day 21 (May 31, 2020).  
 
You have been asked to pay a $160 copayment for a SNF stay. A SNF stay falls within the SNF 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 a SNF stay.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on May 19, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Comprehensive Genomic Profile (CGP) testing (i.e. Guardant-360 and NEXT-Generation) 
requires use of CPT 81479 (for the entire multi-test panel). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on May 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled home health hospice services coded as G0151, 
G0157, Q5001 and G0299 provided February 10, 2020 through March 3, 2020. 
 
You asked the Plan to pay for the skilled home health hospice services. You say that please review this claim 
again as the UB04 form had the HIPPS codes on the claim. The Plan denied your request. The Plan says claim 
was billed without a valid HIPPS code. 
 
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, an expired HIPPS code 1BGP1 was billed for the claim billing period from February 10, 2020 
through March 03, 2020.  Therefore, as an invalid HIPPS code was billed which is a required element for HH 
PPS claims, we decided that Medicare rules for coverage of the skilled home health hospice services have not 
been met. Therefore, we decided that the Plan does not have to pay for the skilled home health hospice services 
coded as G0151, G0157, Q5001 and G0299 provided February 10, 2020 through March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a knee brace provided by a participating 
provider on October 1, 2019. 
 
You asked the Plan to waive the coinsurance for a knee brace. You say that the brace didn't fit properly. You 
say that this is too expensive. 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 durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for a knee brace. The total allowed 
amount is $736.96. The total amount you are being asked to pay is $147.39 ($736.96 x 20% = $147.39). Since 
a knee brace was provided, the correct coinsurance has been applied. A knee brace falls within the durable 
medical equipment 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 knee brace 
provided by a participating provider on October 1, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on November 21, 
2019 through January 30, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because 
this is not  durable medical equipment and was not delivered to the member's home. The Plan denied your 
request. The Plan says S codes are not payable by Original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) 
provided on November 21, 2019 through January 30, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room (ER) visit you had on April 16, 2020.You asked the Plan to waive the copayment forthe ER visit. You say that you thought the copayment was $65.  You also stated that the ER didn't do much for you.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 $90 copayment for emergency room services. You have been asked to pay a $90 copayment for the ER visit. 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 forthe emergency room (ER) visit you had on April 16, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided from January 17, 2020, 
through January 30, 2020. 
 
You asked the Plan to pay for skilled nursing services. You say that this is a home health service not hospice. 
You say that this should be reprocessed for payment. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
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 January 14, 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 skilled nursing 
services provided from January 17, 2020, through January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care. 
 
You asked the Plan to pay for the acute inpatient level of care. You say that please see attached documentation 
that proved medical records were sent back on 3/27/2020 and 04/03/2020. The Plan denied your request. The 
Plan says the enrollee's hospital admission date is prior to enrollment into to the plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the plan that covered the enrollee at the 
beginning of an inpatient stay is responsible for the entire stay. If there is a change in coverage during the stay, 
the new Plan is not responsible for inpatient hospital care until after the date of discharge.  
 
A different health plan was not the Plan of record at the time of the inpatient stay at issue in this appeal began. 
This means that the new plan is not responsible for coverage of inpatient hospital services until after this stay 
ended. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), the extraction 
(D7210), general anesthesia (D9222), and an additional 15 minutes of general anesthesia (D9223) provided 
 by the out of network dentist. 
 
You asked the Plan to reimburse you for the dental services. You say that you have previously been reimbursed 
$100 for dental services that you received from an out of network dentist. You say that you thought you would 
also be reimbursed for future amounts from out of network dentists. The Plan denied your request. The Plan 
says the dentist in this case is not a network dentist. The Plan says that you must use an in network dentist in 
order for the services to be 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 dental services that you receive out 
of network are not covered. The Evidence of Coverage clearly states that you must use a network dentist for the 
services to be covered. Therefore, we decided that the Plan does not have to reimburse you for the limited oral 
evaluation (D0140), the extraction (D7210), general anesthesia (D9222), and an additional 15 minutes of 
general anesthesia (D9223) provided by the out of network dentist.