Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation, extraction and adjunctive 
procedure provided on February 18, 2020 and February 26, 2020. 
 
You asked the Plan to pay for the limited oral evaluation, extraction and adjunctive procedure. You say that 
you had the additional dental and assumed this would be covered. You say that a portion should have been 
covered by insurance. The Plan denied your request. The Plan says the claims processed correctly. 
 
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 amount you are being asked to pay 
is correct. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation, extraction 
and adjunctive procedure provided on February 18, 2020 and February 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays (73564) provided February 25, 
2020. 
 
You asked the Plan to waive the copayment for the x-rays. You say that the copayment should be waived. 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 $35 
copayment for X-rays.  
 
You have been asked to pay a $35 copayment for the x-rays. The x-rays fall within the X-rays 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 x-rays (73564) provided February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit services (CPT 99215) provided to the enrollee on 
January 17, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the services exceeds the maximum number of times this procedure can be allowed on a single 
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. 
 
In this case, the CPT Code Manual definition of code 99215 is "Office or other outpatient visit for the 
evaluation and management of an established patient." 
 
We find that CPT code 99215 is not supported in the medical record. Specifically, a claim for a provider in the 
same group practice was already paid for this date of service. Another claim for a different provider in the same 
group practice cannot be paid. 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 office visit services 
(CPT 99215) provided to the enrollee on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered 
from February 24, 2020 to February 25, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you were in the coronary care unit 
and should not be charged. 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 $150 
copayment for each Medicare-covered outpatient hospital facility visit, clinic, outpatient treatment room, 
observation room, or outpatient surgery services.  
 
Review of the file shows that you received outpatient hospital services from February 24, 2020 to February 25, 
2020. The records support that you were not admitted under inpatient status. You have been asked to pay a 
$150 copayment for these services. These services fall within the Medicare-covered outpatient hospital facility 
visit, clinic, outpatient treatment room, observation room, or outpatient surgery 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 hospital services rendered from February 24, 
2020 to February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown provided on February 18, 2020 by an OON 
provider. 
 
You asked the Plan to pay more for the crown. You say that you think the Plan should have paid more for the 
crown. The Plan denied your request. The Plan says this claim was processed at the network allowable rate. 
The Plan also says that OON dental providers can bill you for the difference between the billed amount and the 
paid amount. 
 
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, you are responsible for the difference 
between the billed amount and the paid amount. Therefore, we decided that the Plan does not have to pay more 
for the crown provided on February 18, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the 
enrollee on December 12, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 remains 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 HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) 
drug identification methods able to identify individual drugs and distinguish between structural isomers (but 
not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any 
type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods 
(e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all 
samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or 
drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations 
and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 
or more drug class(es), including metabolite(s) if performed." 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
provided records do not contain a valid physician order or requisition related to the testing from 12/12/2019 to 
support HCPCS G0483. The provided notes did not include sufficient supportive evidence of the exact tests 
ordered and performed on this date. 
 
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 pay for drug testing services (HCPCS G0483) provided to the enrollee on December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided to the enrollee on August 21. 2019 and 
billed under codes 80307 and G0481. 
 
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 Medicare coverage criteria were not met. 
 
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of 
testing. The physicians order and the medical records must specifically show how this testing will be used to 
treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for 
screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we 
decided that the Plan does not have to pay for drug testing provided to the enrollee. Therefore, we decided that 
the Plan does not have to pay for drug testing provided to the enrollee on August 21. 2019 and billed under 
codes 80307 and G0481.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a chest x-ray (71045) provided on February 17, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that CPT code 71045 is a column II code to CPT code 
74022. 
 
The Plan must follow Medicare rules. Medicare rules say that MACs subject all line items for the same 
beneficiary, same NPI, and same date of service to NCCI edits. 
 
We find that CPT code 71045 is supported in the record. Specifically, the record indicates that the column I and 
column II codes are issue were rendered by separate providers. NCCI edits do not apply when the services are 
rendered by different providers. Based on this information, we decided that Medicare rules for coverage of the 
chest x-ray have been met. Therefore, we decided that the Plan has to pay for a chest x-ray (71045) provided on 
February 17, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the romosozumab-aqqg injection or the 
copayment for outpatient hospital services provided on April 13, 2020. 
 
You asked the Plan to waive the coinsurance for the romosozumab-aqqg injection and the copayment for 
outpatient hospital services. The Plan denied your request. The Plan says the claim paid 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 20% 
coinsurance for Medicare Part B prescription drugs and a $100 copayment for Outpatient diagnostic tests and 
therapeutic services and supplies provided in an outpatient hospital.  
 
You have been asked to pay a 20% coinsurance for the romosozumab-aqqg injection and a $60.47 copayment 
for the outpatient hospital services. The romosozumab-aqqg injection falls within the Medicare Part B 
prescription drugs and outpatient hospital services falls within the Outpatient diagnostic tests and therapeutic 
services and supplies provided in an outpatient hospital benefit category. This means that you have been asked 
to pay less than 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 the romosozumab-aqqg injection and the copayment for outpatient hospital 
services provided on April 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 23, 2020. 
 
You asked the Plan to pay for the physician's services. 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 physician's services provided on January 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Medicare Part B drug services 
rendered from March 9, 2020 to March 11, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Medicare Part B-covered chemotherapy drugs and other Medicare Part B-covered drugs.  
 
Review of the file shows that you received iodine therapy and thyrotropin injections from March 9, 2020 to 
March 11, 2020. You have been asked to pay a 20% coinsurance for these services. These services fall within 
the Medicare Part B-covered chemotherapy drugs and other Medicare Part B-covered drugs 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 the Medicare Part B drug services rendered from March 9, 
2020 to March 11, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to hold you harmless for inpatient mental health services provided on February 
28, 2020 through March 6, 2020. 
 
You asked the Plan to hold you harmless for the inpatient mental health services. You say that you would like 
reconsideration because this admission was the result of an emergency room visit. The Plan denied your 
request. The Plan says that pre-approval was not obtained for the inpatient admission. 
 
The Plan must follow Medicare rules. The Plan Contract says that member's must use network providers with 
limited exceptions, such as emergencies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient mental health services have been met. Specifically, the record supports your 
allegation that you were admitted to the facility through the emergency department. This indicates that these 
services were emergent/urgent. Therefore, we decided that the Plan has to hold you harmless for inpatient 
mental health services provided on February 28, 2020 through March 6, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS HF device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says that medical studies have not proven that this device is helpful for treatment of the
enrollee's health problem.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
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 device. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee has symptomatic Class III CHF and has been recently hospitalized for this. He requires
multiple medications including multiple diuretics and regular CHF clinic visits to maintain his volume status
and prevent relapses of CHF. He was recently treated with IV diuretics in the outpatient setting since his May
2020 hospitalization as well to manage volume overload. He requires regular adjustments of his diuretics and
close monitoring of fluid status on a daily basis. Cardiomems monitors have shown benefit in this exact patient
sub-group to allow for better titration of diuretics and medications to control fluid status and prevent recurrent
hospitalization. Implantation of Cardiomems is therefore reasonable and medical necessary in the treatment of
his changing clinical condition to allow for optimal titration of his medications to prevent re-hospitalization.
Per the CMS guidelines, it is safe and effective and neither experimental or investigational in this clinical
scenario based on the published data.
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 device have been met. Therefore, we decided that the Plan has to preapprove
the CardioMEMS HF device for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for hospital discharge day management services (CPT 99239) provided to 
the enrollee on January 28, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that Current Procedural Terminology (CPT) code 99239 remains 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 CPT 99239 is "Hospital discharge day management; 
more than 30 minutes." 
 
We looked at the file and Medicare rules. We find that CPT code CPT 99239 is supported in the medical 
record. Specifically, the Discharge Summary Attestation, signed by the physician, states "Time Coordinating 
Discharge greater than 30 minutes." Based on this information, we decided that Medicare rules for coverage of 
the services have been met. Therefore, we decided that the Plan has to pay for hospital discharge day 
management services (CPT 99239) provided to the enrollee on January 28, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the air ambulance services provided on October 
30, 2019. 
 
You asked the Plan to reimburse you for the air ambulance services. You say that because of your medical 
condition you were not able to fly commercial airlines. The Plan denied your request. The Plan says return trips 
from a foreign hospital are not covered. 
 
Medicare rules say transportation from one hospital to another hospital is covered only if the hospital to which 
the patient is transferred is the nearest one with appropriate facilities. The Plan follows the same rules. You 
were not transported to the nearest appropriate facility. Transportation back to the United States is not covered 
by the Plan.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the air ambulance services have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for the air ambulance services provided on October 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided November 4, 
2019. 
 
You asked the Plan to pay for the orthosis. You say that please review the information for payment of services 
rendered to the enrollee. The Plan denied your request. The Plan says the enrollee is not eligible for telehealth 
services, there is no actual physical exam, all information was provided over the phone, there is no evidence of 
an established relationship between the enrollee and the ordering physician, there was no claims submitted for 
an evaluation and management service and there is no evidence of a prior telehealth service with the ordering 
physician as required per CMS guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis 
(L0650) provided November 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomographic angiography, lower 
extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing 
(CPT Code 73706) on August 30, 2019. 
 
You asked the Plan to waive the copayment for the diagnostic radiology service. You say that no cost-share 
should apply because you already paid a $285 copayment. The Plan denied your request. The Plan says the 
claim was processed accordingly with your 2019 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 show that you received computed tomographic angiography, lower extremity, with contrast 
material(s), including noncontrast images, if performed, and image postprocessing (CPT Code 73706) on 
August 30, 2019. You are asked to pay a $150 copayment. Your EOC states that enrollees must pay a $150.00 
copayment for covered diagnostic radiology services in a provider's office or freestanding radiology 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 computed tomographic angiography, lower extremity, with 
contrast material(s), including noncontrast images, if performed, and image postprocessing (CPT Code 73706) 
on August 30, 2019.