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

We decided that the Plan does not have topay forcomprehensive genomic profile (CGP) testing provided on May 19, 2020.You asked the Plan to pay forgenetic testing. You say that the enrollee's treating physician ordered this testing to determine if there was a more effective therapy for the enrollee's condition.The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with the appropriate coding.The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 for date of service May 19, 2020. We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on thisinformation, 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 forcomprehensive genomic profile (CGP) testing provided on May 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment physical therapy services received from 
February 24, 2020 to April 16, 2020. 
 
You asked the Plan to waive the copayment the services. You say that the copayments should be waived 
because of the coronavirus. The Plan denied your request. The Plan says the copayments were applied correctly 
in this case. 
 
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 
copayment for outpatient physical therapy services.  
 
You have been asked to pay a $40 copayment for each of these visits in this date range at issue. The services 
fall within the outpatient physical therapy 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 physical therapy services received from February 24, 2020 to April 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99152) provided on January 26, 
2020. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did 
not indicate the presence of an independent trained observer to assist in the monitoring of the member's level of 
consciousness and physiological status. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
  
We find that CPT code 99152 is not supported in the record. Specifically, the record does not indicate the 
presence of an independent trained observer. Based on this information, we decided that Medicare rules for 
coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (99152) provided on January 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator, pneumatic compressor, and the 
shoulder elbow wrist hand orthosis provided on March 23, 2020. 
 
You asked the Plan to pay for the electrical stimulator, pneumatic compressor, and the shoulder elbow wrist 
hand orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. 
The Plan says the documentation is missing required information. 
 
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. Review of the file 
shows that the documentation submitted did not include an itemized shipping/billing invoice to indicate the 
specific supplies or proof of delivery for the billed date of service. The 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 the electrical stimulator, pneumatic compressor, and the shoulder elbow wrist hand orthosis 
provided on March 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram (77066). 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that the copayment 
should be waived. The Plan denied your request. The Plan says a diagnostic mammogram is different than a 
screening mammogram and 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 $100 
copayment for Diagnostic Testing.  
 
You have been asked to pay a $100 copayment for the diagnostic mammogram. The diagnostic mammogram 
falls within the Diagnostic Testing 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 
diagnostic mammogram (77066).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on March 9, 2020. 
 
You asked the Plan to pay more for dental services. You say that these appointments were to stop damage to 
your organs. You say that the claim should be processed under medical not dental. The Plan denied your 
request. The Plan says you have been reimbursed the maximum allowance for non-Medicare covered dental 
services. 
 
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 also have an annual allowance of 
$400 for non-Medicare covered preventive and comprehensive dental services. The Plan paid $400 toward 
dental services received on March 9, 2020, which exhausted your benefit. Therefore, we decided that the Plan 
does not have to pay more for dental services provided on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on June 29, 2020.You asked the Plan to waive the copayment for a specialist office visit. You say that you saw him for less than 5 minutes. You say that the doctor did nothing for you to help you going forward with a hip surgery. 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 $35 copayment for physician/practitioner services/specialist visit. You have been asked to pay a $35 copayment for a specialist office visit. Since a specialist office visit was provided, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner services/specialist visit 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 specialist office visit provided by a participating provider on June 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397, 
L2385) provided to the enrollee on April 8, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says there is no itemized shipping/billing invoice to verify the billed service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. There is no itemized billing/shipping invoice to 
verify the services billed. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for a knee orthosis 
with suspension sleeve (L1851, L2397, L2385) provided to the enrollee on April 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fordental services provided from October 8, 2019, to October 24, 2019.You asked the Plan to pay fordental services. You say that these services were not routine dentalservices but were related to an injury you sustained.The Plan denied your request. The Plan says the denial of payment for these services is correct, because Medicare does not cover these dental services and your Plan does not provide any supplemental dental coverage.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay fordental services provided from October 8, 2019, to October 24, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided January 4, 2019 to 
May 8, 2019. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services should be 
covered. The Plan denied your request. The Plan says the claim was not submitted to the plan in a timely 
fashion. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the outpatient mental health services was not filed until May 26, 2020. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided January 
4, 2019 to May 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services provided on May 27, 
2020. 
 
You asked the Plan to waive the copayment for the urgent care services. You say that you could not see your 
regular doctor and you were advised to go to an urgent care facility. 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 $40 
copayment for Urgently Needed Services.  
 
You have been asked to pay a $40 copayment for the urgent care services. the urgent care services falls within 
the Urgently Needed 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 urgent care 
services provided on May 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare pays for ambulance services that meet certain origin and destination requirements. In order to meet this requirement, the ambulance supplier must transport the patient for whom the emergency call was placed. If an ambulance responds to a call but does not transport the person for whom the call was placed, Medicare does not pay for the service. You can find this rule at 42 CFR Section 410.40(f) and in the Medicare Benefit Policy Manual, Chapter 10, Section 10.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81201, 81209, 81162, 81242, 
81292, 81403, 81404, 81295, 81297, 81298, 81317 and 81319 provided on January 6, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 81201, 81209, 81162, 81242, 81292, 81403, 81404, 81295, 81297, 81298, 81317 and 
81319 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 
24B must reflect the location of the patient when the specimen was obtained. The submitted claim form 
indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted 
medical documentation and/or claim history indicates that the specimen was obtained in an office setting place 
of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 
81201, 81209, 81162, 81242, 81292, 81403, 81404, 81295, 81297, 81298, 81317 and 81319 provided on 
January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from April 14, 2020, 
through April 28, 2020. 
 
You asked the Plan to pay for the psychotherapy 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 
psychotherapy services. 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 psychotherapy services provided from April 14, 
2020, through April 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on January 2, 2020. 
 
You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says there 
is no valid referral for this service. 
 
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 ophthalmological services provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from September 12, 2019, to 
September 13, 2019 by an out of network provider. 
 
You asked the Plan to pay for the medical services. You say that the Plan told you the services did not need 
authorization. The Plan denied your request. The Plan says the call notes show the advisement was based on in 
network services. 
 
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 medical services provided from September 12, 
2019, to September 13, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the routine foot care rendered on February 
17, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you've never had to pay more than 
a $5 copayment. 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 $40 
copayment for each Medicare-covered podiatry visit in an office or home setting.  
 
Review of the file shows that you received routine foot care on February 17, 2020. You have been asked to pay 
a $40 copayment for these services. These services fall within the Medicare-covered podiatry visit in an office 
or home setting 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 routine foot care 
rendered on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (99220) provided on February 7, 
2020. 
 
You asked the Plan to pay for the initial observation care. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says a physician may report only one code 
from a range of codes describing an initial E&M service on a single date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management 
(face-to-face) service is provided on the same day to the same patient by the same physician or more than one 
physician in the same specialty in the same group, only one evaluation and management service may be 
reported unless the evaluation and management services are for unrelated problems. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the initial observation care have not been met. Specifically, an evaluation and management service 
billed by this provider was processed and paid for this date of service. Only one evaluation and management 
service may be reported per day. Therefore, we decided that the Plan does not have to pay for initial 
observation care (99220) provided on February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the destruction of lower or sacral spinal facet joint nerves 
with imaging guidance (64635, 64636) provided on January 14, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the destruction of lower or sacral spinal facet joint nerves with imaging 
guidance. You say that you were advised authorization was not required and the member's care was medically 
justified. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the 
provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the destruction of lower or sacral spinal facet joint 
nerves with imaging guidance (64635, 64636) provided on January 14, 2020 by an out of network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
May 20, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service May 20, 2020.  
 
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 
comprehensive genomic profile (CGP) testing provided on May 20, 2020.