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

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided January 26, 2020 to January 27, 2020.You asked the Plan to pay foracute inpatient hospital care. You say that the inpatient care was medically necessary.The Plan denied your request. The Plan says coverage criteria was not met.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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier Emergency and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided January 26, 2020 to January 27, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on May 13, 2020. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you should not owe the copayment 
because the colonoscopy could not be completed. 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 $210 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $210 copayment for a colonoscopy. A colonoscopy falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 colonoscopy provided on May 13, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the medical services provided on October 17, 2019. 
 
You asked the Plan to pay for the services provided. You say that you were assured that the billing had been 
taken care of. The Plan denied your request. The Plan says that preventative medicine services should only be 
performed once per calendar year. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The services at issue were provided by a contract provider. The file does not show that the Plan provided notice 
that the services provided would not be covered. Under Medicare rules, this means the services provided is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the medical services 
provided on October 17, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance angiography, head, without contrast 
(70544) provided May 1, 2020. 
 
You asked the Plan to pay for the diagnostic radiology services. You say that records attached supporting that 
this procedure was performed by your provider. Please review and reprocess the claim for reimbursement 
according to contract. The Plan denied your request. The Plan says payment for this claim/service may have 
been provided in a previous payment. 
 
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 billing of code 70544 was submitted inappropriately due to the bundled relationship of services 
within the specialty group. 70544 is a column II procedure code to the column I procedure, 70551 billed by 
another provider within the same group and same primary specialty. This service has already been paid to 
another physician. This code can only be billed once per day Based on Medicare billing guidelines, this claim 
cannot be paid as billed.  Based on this information, we decided that Medicare rules for coverage of the 
diagnostic radiology services have not been met. Therefore, we decided that the Plan does not have to pay for 
magnetic resonance angiography, head, without contrast (70544) provided May 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan you had on June 5, 2020. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible 
for the copayment. 
 
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 $75 
copayment for CT scans.  
 
Review of the file shows that you had a CT scan on June 5, 2020. You have been asked to pay a $75 
copayment for the CT scan. The CT scan falls within the outpatient diagnostic 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 copayment for the CT scan you had on June 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hydraulic patient lift, includes any seat, sling, strap(s) or 
pad(s) (E0630) provided on January 15, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the hydraulic patient lift. You say that procedure code E0630 is billed as a 
monthly rental. Please also see the attached DME order for the lift. Please review and reprocess for full 
payment promptly. The Plan denied your request. The Plan says there is insufficient documentation to 
corroborate medical necessity and that Medicare coverage criteria has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
  
We find that CPT code E0630 is not supported in the medical record. Specifically, non-participating providers 
are required to furnish necessary information to the health plan when requested. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Based on this information, we 
decided that Medicare rules for coverage of the hydraulic patient lift have not been met. Therefore, we decided 
that the Plan does not have to pay for the hydraulic patient lift, includes any seat, sling, strap(s) or pad(s) 
(E0630) provided on January 15, 2020, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on December 2, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing services provided on December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DME provided on April 22, 2020. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says services rendered by non-
participating 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 
items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided 
that the Plan does not have to pay for DME provided on April 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a seat lift chair and mechanism (A9270, E0627) purchased on April 30, 2020. 
 
You asked the Plan to pay for a seat lift chair and mechanism. You say that the enrollee was not told that she 
had to use a Medicare supplier. The Plan denied your request. The Plan says the supplier this item was 
purchased from does not participate in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The supplier the items at issue were purchased from is not enrolled in 
the Medicare program. Based on this information, we decided that Medicare rules for coverage of a seat lift 
chair and mechanism have not been met. Therefore, we decided that the Plan does not have to pay for a seat lift 
chair and mechanism (A9270, E0627) purchased on April 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nurse visits (CPT Code G0299 x 1 and CPT 
Code G0300 x 20). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says this appeal is no longer valid as the patient's medical condition has changed 
after this recent inpatient stay. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 the services. Our physician reviewer 
found the records do not show that additional skilled nursing services are required to effectively provide 
treatment, care, and/or services in order to improve the patient's condition, or to establish/perform a 
maintenance program to maintain the patient's condition and/or prevent deterioration. The patient has had prior 
SN for wound care management. The patient's conditions are chronic and there is no evidence of complex 
wound care or other skilled nursing (SN) need. There is no evidence from the patient's physician of the need for 
additional SN visits. The request for additional SN visits is not medically necessary per  Medicare Benefit 
Policy Manual, Chapter 7. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nurse visits (CPT Code G0299 x 1 and CPT Code G0300 x 20).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for remote cardiac monitoring services 
provided by your cardiologist on April 18, 2020, and May 19, 2020. 
 
You asked the Plan to waive the copayments for the remote cardiac monitoring services. You say that no one 
ever told you that you would have to pay any charges for monitoring of the cardiac device. The Plan denied 
your request. The Plan says you were charged these copayments 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 $45 
copayment for specialist services.  
 
You have been asked to pay $45 copayment for the remote cardiac monitoring services. The remote cardiac 
monitoring services falls within the specialist services benefit category because your Evidence of Coverage 
says that specialist services includes remote evaluation services. 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 remote cardiac monitoring services provided by your cardiologist on April 18, 2020, and May 
19, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services on April 22, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you have never been billed in the past. 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 April 22, 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 the ambulance services on April 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tissue graft (20926) provided on January 8, 2020. 
 
You asked the Plan to pay for the tissue graft. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says CPT code was not active on the billed date of service. 
 
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 20926 is not supported in the record. Specifically, CPT code 20926 was deleted as of 
December 31, 2019. This was not an active code on the billed date of service. Based on this information, we 
decided that Medicare rules for coverage of the tissue graft have not been met. Therefore, we decided that the 
Plan does not have to pay for a tissue graft (20926) provided on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on October 7, 2019. 
 
You asked the Plan to pay for dental services. You say that you have always been seen in this office and the 
exam and cleaning were covered. You say that you shouldn?t be responsible for payment when you were told it 
would be covered. The Plan denied your request. The Plan says out-of-network dental services are not covered 
benefits. 
 
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, 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 dental 
services provided on October 7, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip and emergency room 
visit provided by a participating provider on May 11, 2020, through May 12, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip and emergency room visit. You say that all 
you wanted to know is if you have Covid-19. The Plan denied your request. The Plan says the correct 
copayments 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 $270 
copayment for ambulance services a $90 copayment for emergency care/in-network/emergency services.  
 
You have been asked to pay a $270 copayment for an ambulance trip a $90 copayment for an emergency room 
visit. The total amount you are being asked to pay is $360 ($270 + $90 = $360). The correct copayments have 
been applied to the services that were provided. An ambulance trip falls within the ambulance services benefit 
category and emergency room visit falls within the emergency care/in-network/emergency 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 an ambulance trip and emergency room visit 
provided by a participating provider on May 11, 2020, through May 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, intraoral x-ray and prophylaxis 
provided on July 6, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation, intraoral x-ray and prophylaxis. You say that you 
had a cleaning and oral exam and it was all denied. The Plan denied your request. The Plan says out-of-network 
dental services are not covered benefits. 
 
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, 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 
periodic oral evaluation, intraoral x-ray and prophylaxis provided on July 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on May 4, 2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you feel that you should only 
owe a $20 copayment for urgent care services. 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 $90 
copayment for emergency care.  
 
The record shows that you received emergency care at an outpatient hospital facility on May 4, 2020. 
Therefore, you are responsible to pay the $90 copayment.  
 
You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 
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 emergency care provided on 
May 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy services coded S9328 provided from February 5, 2019 to May 1, 2019.You asked the Plan to pay forthe home infusion therapy services. You say that you would like the plan to reconsider their denial.The Plan denied yourrequest. The Plan says the services billed are not payable.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 CodeManual definition of code S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that these services are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy services coded S9328 provided from February 5, 2019 to May 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a stay at an IRF from May 10 to May 23, 
2019. 
 
You asked the Plan to waive the copayment for a stay at an IRF. You say that the copayment for a skilled 
nursing facility (SNF) should be applied. The Plan denied your request. The Plan says the correct copayment 
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 a $295 
copayment for each day of days 1 to 6 for each Medicare-covered hospital stay, including inpatient 
rehabilitation.  
 
You have been asked to pay $1,770, or a $295 copayment for each day of days 1 to 6, for a stay at an IRF. A 
stay at an IRF 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 a stay at an IRF from May 10 to May 23, 2019.