Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the respiratory equipment you rented on 
September 15, 2018. 
 
You asked the Plan to waive the coinsurance for the respiratory equipment. You say that you returned this 
equipment in November of 2018 and just now started receiving bills with no explanation.  You also said that 
you don't understand why these charges are different than the first months' charges. The Plan denied your 
request. The Plan says you were charged this coinsurance 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the respiratory equipment. The respiratory equipment falls 
within the durable medical equipment 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. Please note that the reason why the first months bill from the equipment 
company was different is because you received additional purchased items beyond the two rental items (the 
respiratory assist device and related humidifier) on the subsequent claim. Therefore, we decided that the Plan 
does not have to waive the coinsurance for the respiratory equipment you rented on September 15, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on March 5, 2020. 
 
You asked the Plan to pay for foot orthotics. You say that you have severe planter fasciitis and could not walk 
or put pressure on your left fool or heel. You say that you called the Plan, and they say you could go 
to the facility without a referral. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 99152 provided on October 25, 2019. 
 
You asked the Plan to pay for CPT code 99152. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 medical record. Specifically, the medical record does not 
contain evidence that moderate sedation was performed with the presence of an independent trained observer. 
Based on this information, we decided that Medicare rules for coverage of CPT code 99152 have not been met. 
Therefore, we decided that the Plan does not have to pay for CPT code 99152 provided on October 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a surgical treatment of a broken upper-arm 
bone (23615) performed during an outpatient hospital stay from February 28 to March 2, 2020. 
 
You asked the Plan to waive the coinsurance for a surgical treatment of a broken upper-arm bone. You say that 
you understood your stay to have been an inpatient stay. The Plan denied your request. The Plan says the 
correct coinsurance 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 20% 
coinsurance for each surgical or observation room service at an outpatient hospital. 
 
You have been asked to pay $2,371.43, or 20% of the Plan-allowed amount of $11,857.15, for a surgical 
treatment of a broken upper-arm bone. A surgical treatment of a broken upper-arm bone, when performed on 
an outpatient basis, falls within the "Outpatient hospital 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 coinsurance for a surgical treatment of a broken upper-arm bone (23615) performed during an 
outpatient hospital stay from February 28 to March 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on February 13, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you experienced a diabetic emergency and 
the hotel called the ambulance. The EMT's treated you and then confirmed with the attending ER doctor that 
you not be transported. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 13, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 13, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician's services provided on February 26, 2019 and June 11, 2019.

You asked the Plan to pay for the physician's services. You say that you thought that this provider, who was covered under Medicare, would be covered under the new Plan. You say that this provider is convenient for you to travel to the office with your limited transportation options. The Plan denied your request. The Plan says members must use network providers for all care to obtain health plan coverage.

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 physician's 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 the physician's services provided on February 26, 2019 and June 11, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT Scan of the head or brain (70470) provided on 
January 19, 2020. 
 
You asked the Plan to pay for the CT Scan. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the submitted documentation only supports CPT code 
70460 as being performed and not CPT code 70470. 
 
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 70470 is computed tomography, head or brain; without 
contrast material, followed by contrast material(s) and further sections. 
 
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 CT Scan. Our reviewer says that CPT code 70470 does 
not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation submitted 
does not include record of contrast, therefore the documentation supports CPT code 70660 which has already 
been paid. 
 
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 CT Scan have not been met. Therefore, we decided that the Plan does not 
have to pay for the CT Scan of the head or brain (70470) provided on January 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with 
suspension sleeve (L1833, L2397) provided to the enrollee on January 6, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
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 a lumbar-sacral orthosis 
(L0650) and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on January 6, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for routine foot care (11721 and 99308) provided on August 19, 2019.

You asked the Plan to pay for the routine foot care. You say that you would like reconsideration because it is the responsibility of the facility to obtain prior authorization. The Plan denied your request. The Plan says routine foot care is not a Medicare covered benefit.

The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. 

Records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the routine foot care have not been met. Therefore, we decided that the Plan does not have to pay for routine foot care (11721 and 99308) provided on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services provided to the 
enrollee on January 9, 2020 to February 7, 2020. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services from this point were considered custodial care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there was no documentation that the 
enrollee required skilled nursing or skilled therapy services. The enrollee did not require the services on an 
inpatient basis, in a skilled nursing facility for these dates. These services appear to be custodial. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services provided to the enrollee on January 9, 2020 to 
February 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction provided on March 10, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the extraction. You say that the enrollee was not informed that this provider was 
no longer in-network with the Plan for 2020. The Plan denied your request. The Plan says the treating provider 
is OON and is allowed to bill the difference of the allowed amount and their billed amount to you. The Plan 
also says that this claim was processed correctly per the Plan's 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, 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 
extraction provided on March 10, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis (20611) provided on January 3, 2020. 
 
You asked the Plan to pay for arthrocentesis. You say that the records support this code. The Plan denied your 
request. The Plan says the documentation is insufficient. 
 
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 20611 is aspiration and/or injection, major joint or bursa 
(eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and 
reporting. 
 
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 arthrocentesis. Our reviewer says that this 
code is not supported. Our physician reviewer found the procedure report did not include documentation of 
permanent recording and reporting, therefore this procedure cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrocentesis have not been met. Therefore, we decided that the Plan does not 
have to pay for arthrocentesis (20611) provided on January 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Arrhythmia Comprehensive Panel provided on January 
22, 2020. 
 
You asked the Plan to pay for the genetic testing panel. You say that this was ordered by the treating provider 
in order to provide medically necessary information. The Plan denied your request. The Plan says this was 
ordered after a non-covered telehealth consultation and this testing was provided for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. The rules also say that telehealth visits can only substitute for an in-person 
encounter when an interactive audio and video telecommunications system is used from a valid originating site. 
 
The documentation does not include any medical records from the consultation with the ordering physician. 
This physician is in one state and the enrollee is in a different state. There is no evidence that this order was made after 
a valid telehealth visit. Moreover, the documentation does not demonstrate any signs/symptoms of disease for 
which this testing was performed. As such, it is considered screening testing that is excluded from coverage.  
Therefore, we decided that the Plan does not have to pay for the Arrhythmia Comprehensive Panel provided on 
January 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided November 23, 2019 to November 
26, 2019. 
 
You asked the Plan to pay for the inpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says sufficient records were not provided in a timely fashion to support the 
services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. The plan made multiple attempts to obtain medical records to support 
the services at issue. The records provided were for the incorrect service dates. Based on this information, we 
decided that Medicare rules for coverage of the inpatient services have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient services provided November 23, 2019 to November 26, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a psychotherapist office visit (99214) on 
April 10, 2020. 
 
You asked the Plan to waive the copayment for a psychotherapist office visit. You say that this charge is the 
result of a clerical error. 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 $25 
copayment for each Medicare-covered individual or group therapy visit.  
 
You have been asked to pay a $25 copayment for a psychotherapist office visit. A psychotherapist office visit 
falls within the "Outpatient mental health care" benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for a psychotherapist office visit (99214) on April 10, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the surgical assistant services provided during a liver hemorrhage 
repair with total splenectomy on September 5, 2019 billed with CPT codes 38100-AS and 47350-AS. 
 
You asked the Plan to pay for the surgical assistant services. You say that this should be covered. The Plan 
denied your request. The Plan says that a claim for these services was already paid so no payment can be made 
for this claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the documentation clearly shows that the billing provider was 
present as a surgical assistant during this procedure, along with two other surgical assistant providers. The Plan 
states that a claim for these codes was already received and paid but failed to provide any evidence of this. 
Given that there would be an expectation of multiple claims for some of these services due to more than one 
surgical assistant being present, we cannot confirm the Plan's denial rationale without documentation that 
surgical assistant services provided by this particular provider were paid. Therefore, we decided that the Plan 
has to pay for the surgical assistant services provided during a liver hemorrhage repair with total splenectomy 
on September 5, 2019 billed with CPT codes 38100-AS and 47350-AS.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 20, 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 the procedure codes are not covered. 
 
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 81225-90; 81226-90; 81227-90; 81230-90; 81231-90; 81240-90; 81241-90; 81328-90; 
81335-90; 81355-90; 81232-90; 81283-90; and 81408-90 are not supported in the medical record. Specifically, 
there are no laboratory results for the date of service at issue. 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 laboratory services rendered on February 20, 2020.