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 (D0140) and a cone beam CT 
capture (D0364) provided on April 1, 2020. 
 
You asked the Plan to pay for the limited oral evaluation (D0140) and a cone beam CT capture (D0364). You 
submitted your bill for review. You say that the services were done on an emergency basis. The Plan denied 
your request. The Plan says a limited oral evaluation is only covered once per plan year and a cone beam CT 
capture is not a covered benefit. 
 
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 a maximum benefit of 
one limited oral evaluation per plan year. The Plan paid for a limited oral evaluation provided on March 31, 
2020, which exhausted the benefit. The cone beam CT capture is not a covered benefit. Therefore, we decided 
that the Plan does not have to pay for the limited oral evaluation (D0140) and a cone beam CT capture (D0364) 
provided on April 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vision services provided by a participating 
provider on January 9, 2020. 
 
You asked the Plan to waive the copayment for vision services. You say that you do not agree with this 
copayment. 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 $20 
copayment for vision care/ophthalmologist or optometrist.  
 
You have been asked to pay a $20 copayment for vision services. The correct copayment has been applied to 
the services that were provided. Vision services fall within the vision care/ophthalmologist or optometrist 
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 vision services provided by a 
participating provider on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound repair (12034) provided on January 16, 2020. 
 
You asked the Plan to pay for the wound repair. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
the service billed. 
 
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 12034 is repair, intermediate, wounds of scalp, axillae, 
trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm.  
 
We asked our coder 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 wound repair. Our reviewer says that CPT code 12034 
does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records 
provided do not include sufficient documentation to corroborate that a Repair, intermediate, wounds of scalp, 
axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm was performed on the billed 
date of service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the wound repair have not been met. Therefore, we decided that the Plan does 
not have to pay for wound repair (12034) provided on January 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 11, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
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 lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on December 11, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on January 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
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 January 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office services provided on March 13, 
2020 by an out-of-network provider. 
 
You asked the Plan to waive the copayment for the office services. You say that there were no in-network 
providers who would do this procedure. 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 show that you received the office services provided on March 13, 2020 by an out-of-network 
provider. You were asked to pay 50% coinsurance for the office services. Your EOC states that enrollees must 
pay 50% coinsurance for out-of-network Physician/Practitioner services, including doctor's office visits. 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 office services provided on March 13, 2020 by an out-
of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on March 4, 2020. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you don't think that you should have 
to pay for additional payments. The Plan denied your request. The Plan says the correct coinsurance has been 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $1,170.64. The total amount you are being asked to pay is $234.12 ($1,170.64 x 20% = $234.12). An 
injection falls within the Medicare Part B prescription 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 an injection provided by a participating provider on March 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the services provided on June 6, 2020. 
 
You asked the Plan to waive the copayment for the services. You say that all services provided should have 
been submitted under emergency room services and not under observation. 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).  
 
The medical records provided clearly show you received observation and computed tomography (CT) services 
on June 06, 2020. You are asked to pay a $210 copayment for the observation services and a $200 copayment 
for the CT scan. 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 services provided on June 6, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital outpatient clinic visit for 
assessment and management of a patient provided on January 14, 2020. 
 
You asked the Plan to waive the copayment for the office services.. 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 show that you received the specialist office services on January 14, 2020. You are asked to 
pay a $10 copayment for the 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 copayment for hospital outpatient 
clinic visit for assessment and management of a patient provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (G0463, 90632, 90647 90670, 90746, 
90750 G0009, G0010) provided March 4, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not billed correctly. 
 
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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient services (G0463, 90632, 90647 90670, 90746, 90750 G0009, G0010) have not been 
met. Specifically, code 90750 has a Status Indicator of "M", which means it is not billable to or paid by the 
Medicare Administrative Contractor (MAC). The claim is therefore not payable as billed. Therefore, we 
decided that the Plan does not have to pay for outpatient services (G0463, 90632, 90647 90670, 90746, 90750 
G0009, G0010) provided March 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 13, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the billed CPT codes are not supported in the medical record. Specifically, the services were billed 
as if the specimen was collected by blood sampling. However, the records show that the specimen was 
collected by urine sample. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on January 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May 
29, 2019 through June 5, 2019. 
 
You asked the Plan to waive the copayment for inpatient hospital care. 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 were admitted on May 29, 2019 and discharged on June 5, 2019. You were 
asked to pay a $245 copayment per day from May 29, 2019 through June 3, 2019, days 1-6 of your inpatient 
stay. There were no copayment charges from June 4, 2019, day 7 of your inpatient hospital care until your day 
of discharge June 5, 2019. Per your contract there is a $245 copayment per day required for days 1-6. 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 inpatient hospital care provided from May 29, 2019 through 
June 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a blood transfusion provided on May 22, 
2019. 
 
You asked the Plan to waive the copayment for a blood transfusion. You say that you disagree with the charges 
because the enrollee was never charged in the past. The Plan denied your request. The Plan says the claims 
were processed correctly, and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers.  
 
The enrollee received a blood transfusion on May 22, 2019 at an outpatient hospital facility. A blood 
transfusion is considered an outpatient surgical procedure. Therefore, the enrollee is responsible to pay the 
$250 copayment.  
 
The enrollee has been asked to pay a $250 copayment for a blood transfusion. A blood transfusion falls within 
the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers benefit category. This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a blood transfusion 
provided on May 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on March 2, 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 70450 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70496 and 70450. Code 70450 is a column II code with a 
modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the 
computed tomography (CT) scan of the head/brain rendered on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office services provided on April 3, 
2020. 
 
You asked the Plan to waive the copayment for the office services. You say that you do not recall going to this 
provider or having a body mass index test done either. 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 show that you received the office services provided on April 3, 2020. The medical records 
indicate that you presented to the office for a sick visit with complaints of a rash on the side of your face. You 
were prescribed Cephalexin 500 mg and referred to a dermatologist for further evaluation. Your pharmacy 
claims confirm that the Cephalexin 500 mg was filled on April 3, 2020. The Medicare-allowed amount for the 
office services is less than the set $20 copayment; therefore, you have been asked to pay the lesser amount of 
$15.29 for the office services. Your EOC states that enrollees must pay a $20 copayment in a Physician?s 
office. 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 office services provided on April 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on March 27, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 skilled nursing services provided on March 27, 
2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 25, 
2020 to March 27, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient admission was appropriate. 
The Plan denied your request. The Plan says the enrollee could have been treated at a lower level of care. 
 
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 enrollee presented for a scheduled open reduction and internal fixation of the 
proximal humerus following a fracture related to a fall 2 weeks prior. He had no reported numbness or signs of 
paresthesia or neurovascular deficits. It was determined that there was no contraindication to surgery or 
anesthesia. He was admitted to the hospital and started on IV fluids and prepared for surgery. Based on the 
provided documentation, the patient did not have any expected complications or major risk factors which 
would have expected a prolonged recovery in the hospital following surgery. There was no indication inpatient 
services would have been needed for at least 2 midnights at the time of admission prior to surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this 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 for the acute inpatient hospital care provided from March 25, 2020 to March 27, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 9, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
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. The records provided do not contain 
documentation of the ordering physician?s intent that the tests be performed. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on January 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care services provided from October 27, 2019 to 
December 31, 2019. 
 
You asked the Plan to pay for home health care services. You say that the participating providers you were 
given a list of would not come to the enrollee's home. The Plan denied your request. The Plan says services 
from providers that are not enrolled in Medicare are not covered. 
 
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 provider that the enrollee received these services from is not 
enrolled in the Medicare program. Based on this information, we decided that Medicare rules for coverage of 
home health care services have not been met. Therefore, we decided that the Plan does not have to pay for 
home health care services provided from October 27, 2019 to December 31, 2019.