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

 
We decided that the Plan does not have to pay for emergency room services provided to the enrollee on January 
28, 2020 and billed under code 99285. 
 
You asked the Plan to pay emergency room services. You say that this claim should be paid as billed. The Plan 
denied your request. The Plan says based on the records provided, the more appropriate code to bill would have 
been 99284 which was approved for payment based on the treatment and the diagnosis. 
 
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 records provided do not support 
the services billed for code 99285.  Based on this information, we decided that Medicare rules for coverage of 
this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for emergency 
room services provided to the enrollee on January 28, 2020 and billed under code 99285.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on April 14, 2020. 
 
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 Plan says this is an administrative determination for coding and is not based on 
clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use 
of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field. 
 
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 claim is missing the main code 
and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of 
this claim have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
provided to the enrollee on April 14, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from December 25, 
2019 to January 8, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled 
Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from July 16, 2019 to 
December 24, 2019. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing services provided from December 25, 2019 to January 
8, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided from March 30, 
2020 to May 4, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided from March 30, 2020 
to May 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient cardiac rehabilitation 
services provided February 19, 2020 to February 28, 2020. 
 
You asked the Plan to waive the copayment for the outpatient cardiac rehabilitation services. You say that you 
do not know why you were charged for 11 visits, $440 for cardiac rehab. You are paying for the insurance and 
thought you were covered. The Plan denied your request. The Plan says this claim was processed correctly per 
the plan benefits. 
 
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 $40 
copayment for each outpatient hospital visit.  
 
You have been asked to pay $440 for the outpatient cardiac rehabilitation services. The outpatient cardiac 
rehabilitation services fall within the Cardiac 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 the outpatient cardiac rehabilitation services provided February 19, 2020 to 
February 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1833) and suspension sleeve (L2397) 
provided on January 17, 2020. 
 
You asked the Plan to pay for a knee orthosis and suspension sleeve. You say that this was medically 
necessary. The Plan denied your request. The Plan says the necessity cannot be verified. 
 
The Plan must follow Medicare rules. The rules state if the information in the patient's medical record does not 
adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Without medical records, the medical necessity of these items 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 (L1833) and suspension sleeve (L2397) 
provided on January 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on August 21, 2019. 
 
You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare. The Plan denied 
your request. The Plan says the denial of payment for this testing is correct, because this testing has not been 
billed with the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT 
code 81479 for date of service August 21, 2019.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
Guardant360 testing provided on August 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular procedure provided on January 14, 2020. 
 
You asked the Plan to pay for the services provided. You say that there is currently no established CPT code 
for the procedure. The Plan denied your request. The Plan says a valid clinical trial number was not entered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. 
 
 
We find that the service at issue was not billed with a valid modifier or clinical trial number. Based on this 
information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the cardiovascular procedure provided on January 
14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 25, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services received are not a covered benefit when provided by 
an OON 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 office visit provided on February 25, 2020 by 
an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 11, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the patient could have been safely transported by another type of motor 
vehicle, possibly a van transport vehicle and there is a CPT-code modifier (-GY) for ambulance / emergency 
medical services response without transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 the ambulance services. Our physician 
reviewer found based on the medical records provided there is no documentation that support that other means 
of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were 
contraindicated for this patient. Based on the medical records provided there is no documentation that support 
that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-
equipped ambulance can provide for safe transport. The patient had essentially normal vital signs and exam 
with a Glasgow Coma Scale score of 15 with no other signs or symptoms of an acute unstable medical 
condition. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance services provided on March 11, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the specialist telehealth services provided Mary 21, 
2020. 
 
You asked the Plan to waive the copayment for the telehealth. You say that there was no office visit. This was 
done by telephone. You had to take your own vitals and weight and the conversation with the doctor was no 
longer than 5 minutes. The Plan denied your request. The Plan says that per the plan benefits the claim 
processed correctly with the $35 copay for specialist telehealth services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $10 telephonic and web-based medical consultation, 
diagnosis and/or treatment of urgent conditions for Physician/practitioner services, including doctor's office 
visits.  
 
The Plan says you must pay $35 for each specialist visit for Medicare covered services for the telehealth. Based 
on the Plan contract, however, you cannot be asked to pay more than $10 copayment for telephonic and web-
based medical consultation, diagnosis and/or treatment of urgent conditions for the telehealth. Therefore, we 
decided that the Plan has to waive the $35 copayment for the specialist telehealth services and apply the correct 
$10 copayment for the telehealth services provided Mary 21, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the biopsy performed on November 7, 2019 
at an in-network outpatient department. 
 
You asked the Plan to waive the copayment for the biopsy. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows that you had a biopsy performed at the outpatient hospital facility on November 7, 
2019. You were asked to pay a $150 copayment because the biopsy is considered a surgery. Your EOC states 
that enrollees must pay a $150 copayment for each in-network Medicare-covered outpatient surgery or 
procedure at an outpatient hospital facility of ambulatory surgical center. 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 biopsy performed on November 7, 2019 at an in-network outpatient department.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for facility services provided by a participating 
provider on March 16, 2020. 
 
You asked the Plan to waive the copayment for facility services. You say that you do not know why you are 
being charged a facility fee. The Plan denied your request. The Plan says when you visit a provider, you may 
be charged an additional fee. The Plan says that an additional copayment was correctly 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 doctor visit/specialist.  
 
You have been asked to pay a $30 copayment for facility services. Facility services fall within the doctor 
visit/specialist 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 facility services provided 
by a participating provider on March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $26.38 copayment for physician services provided on 
March 6, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this cost share is correct. The 
Plan denied your request. The Plan says you are a dual eligible enrollee. Any claims not covered by Medicare 
or that reflect cost share with Medicare should be submitted to your Medicaid benefit for further review. The 
Plan states this is explained in the Plan contract. 
 
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 explains for enrollees who are dual eligible providers 
can submit to both Medicare and Medicaid for payment of their care and services. The Plan has explained that 
the $26.38 owed for the services provided should be submitted to Medicaid and that you would not be 
responsible for this payment. Therefore, we decided that the Plan does not have to waive the $26.38 copayment 
for physician services provided on March 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the autogenous connective tissue graft procedure of the first 
tooth (D4273), autogenous connective tissue graft procedure of each additional contiguous tooth (D4283), free 
soft tissue graft procedure of the first tooth (D4277), and free soft tissue graft procedure of each additional 
contiguous tooth (D4278) provided on February 11, 2020 and March 17, 2020. 
 
You asked the Plan to pay for the autogenous connective tissue graft procedures and free soft tissue graft 
procedures. The Plan denied your request. The Plan says these services are not covered benefits under 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 
autogenous connective tissue graft procedure of the first tooth (D4273), autogenous connective tissue graft 
procedure of each additional contiguous tooth (D4283), free soft tissue graft procedure of the first tooth 
(D4277), and free soft tissue graft procedure of each additional contiguous tooth (D4278) provided on February 
11, 2020 and March 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the odontoplasty provided on March 30, 2020. 
 
You asked the Plan to pay for the odontoplasty. You say that you were told that the provider accepted your 
insurance, and you were approved for this appointment. The Plan denied your request. The Plan says this 
service is not 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. Therefore, we decided that the Plan does not have to pay for the 
odontoplasty provided on March 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound guidance rendered on January 29, 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 procedure code 76937 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 76937 is ultrasound guidance for vascular access 
requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent 
realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List 
separately in addition to code for primary procedure). 
 
We find that CPT code 76937 is not supported in the medical record. Specifically, there is no documentation of 
permanently recorded images. 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 ultrasound 
guidance rendered on January 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the insertion of a new or replacement of a 
permanent pacemaker (33208) provided on February 12, 2020. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the service 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 40% 
coinsurance for out of network Medicare-covered surgery or other services provided to you at an ambulatory 
surgical center/outpatient hospital, including but not limited to hospital or other facility charges and physician 
or surgical charges.   
 
You have been asked to pay $3,059.33($7,648.32 allowed amount x 40% coinsurance) for the outpatient 
surgery. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
Additionally, the record shows that you issued payment to the provider in the amount of $395; therefore, your 
balance owed for this service is $2,664.33. 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 the 
insertion of a new or replacement of a permanent pacemaker (33208) provided on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered on January 3, 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 procedure code 99292 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 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
We find that CPT code 99292 is not supported in the medical record. Specifically, there is no documentation of 
an additional 30 minutes of critical care time spent on the enrollee, in addition to the first 30-74 minutes. 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 critical care services rendered on January 3, 
2020.