Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from October 
19, 2019 through October 24, 2019. 
 
You asked the Plan to pay for post-stabilization care. You say that the stay was medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post-stabilization care. Our physician 
reviewer found the review indicates that the enrollee was hemodynamically stable and appropriate for 
ambulance transport with monitoring to a Plan facility after the emergency room evaluation on October 19, 
2019. There was no documentation provided requiring post-stabilization care services October 19, 2019 
through October 24, 2019 at the non-participating facility. The review has determined that the treating 
physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for 
transfer on any dates of service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan 
does not have to pay for post-stabilization care provided to the enrollee from October 19, 2019 through October 
24, 2019.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an outpatient hospital facility visit provided on April 
16, 2020. 
 
You asked the Plan to waive the copayment for an outpatient hospital facility visit. You say that you disagree 
with the charges because you should not owe a copayment for laboratory services. The Plan denied your 
request. The Plan says that the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copayment for outpatient hospital coverage.  
 
The Plan says you must pay a $30 copayment for an outpatient hospital facility visit. Based on the Plan 
contract, however, you cannot be asked to pay for outpatient hospital coverage. Therefore, we decided that the 
Plan has to waive the copayment for an outpatient hospital facility visit provided on April 16, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the CPAP headgear and nasal mask 
cushions provided on November 13, 2019. 
 
You asked the Plan to waive the coinsurance for these items. The Plan denied your request. The Plan says that 
the enrollee owes cost sharing for these items. 
 
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 20% coinsurance for Durable medical equipment (DME) and related supplies.  
 
The enrollee has been asked to pay a 20% coinsurance for these items. These items fall within the Durable 
medical equipment (DME) and related supplies 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 coinsurance for the CPAP headgear and nasal mask cushions provided on November 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis, periodic oral evaluation and bitewing x-rays 
provided on December 2, 2019. 
 
You asked the Plan to pay for the prophylaxis, periodic oral evaluation and bitewing x-rays. You say that you 
have out-of-network benefits. You say that the claim should be paid and you should be refunded. The Plan 
denied your request. The Plan says out-of-network dental services are not covered benefits. 
 
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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
prophylaxis, periodic oral evaluation and bitewing x-rays provided on December 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services (CPT 77006) provided to the 
enrollee on January 8, 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 this was 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. 
 
In this case, the CPT Code Manual definition of code 77066 is "Diagnostic mammography, including 
computer-aided detection (CAD) when performed." 
 
We asked our coding 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 coding reviewer found when the 
professional interpretation of the diagnostic test is billed separately from the technical component as indicated 
by modifier 26, the billing agent must report the interpreting physician's location (address and zip code) on the 
claim. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for diagnostic radiology services (CPT 77006) provided to the enrollee on January 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunohistochemistry services coded 88342 provided on 
October 29, 2019. 
 
You asked the Plan to pay for the immunohistochemistry services. You say that you would like the pan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not separately 
payable. 
 
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 88342 is Immunohistochemistry or 
immunocytochemistry, per specimen; initial single antibody stain procedure. 
 
We find that CPT code 88342 is not supported in the medical record. Specifically, this code was previously 
processed and paid under another claim. Separate payment is not allowed. Based on this information, we 
decided that Medicare rules for coverage of the immunohistochemistry services have not been met. Therefore, 
we decided that the Plan does not have to pay for the immunohistochemistry services coded 88342 provided on 
October 29, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $200 copayment charged for ambulance transport provided on March 26, 2020.
You asked the Plan to waive this copayment. You say that you would like the copayment waived because it was recommended you take the ambulance due to Covid. The Plan denied your request. The Plan says this copayment was charged based on the Plan contract agreement for this type of service.
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 $200 copayment for ambulance transport. 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 $200 copayment charged for ambulance transport provided on March 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on December 
27, 2019. 
 
You asked the Plan to waive the copayment for the laboratory work. You say that this was your yearly visit 
with your provider and not a hospital clinic. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing 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). Your contract with the Plan clearly says that you must pay a $40 
copayment for laboratory services at an in-network outpatient hospital. For this date of service, you have been 
asked to pay the allowed amount of the claim because this amount is less than the $40 copayment for the 
laboratory work. 
 
You have been asked to pay a $21.92 copayment for the laboratory work. The laboratory work falls within the 
"Outpatient diagnostic tests and therapeutic services and supplies" 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 laboratory work provided on December 27, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray and an ultrasound provided by a 
participating provider on January 3, 2020. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests. You say that you do not agree with 
such a big 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 $10 
copayment for outpatient diagnostic tests/x-rays and ultrasounds.  
 
You have been asked to pay a $10 copayment for each outpatient diagnostic test. The total amount you are 
being asked to pay is $20 ($10 x-ray + $10 ultrasound = $20). Outpatient diagnostic tests fall within the 
outpatient diagnostic tests/x-rays and ultrasounds 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 an x-ray and an ultrasound provided by a participating provider on January 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from March 17, 2018 to March 30, 2018.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says this Plan allows for out-of-network coverage for emergency services or when there are no in-network providers available. The non-contracted provider did not obtain authorization by the Plan to provide compensated care. The services were not in association with an emergency.
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 SNF 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 SNF services provided from March 17, 2018 to March 30, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable gaseous oxygen system (E0430) purchased on 
March 23, 2020 from a non-Medicare provider. 
 
You asked the Plan to pay for the DME. You say that you are requesting reimbursement of services rendered. 
The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
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. 
 
Review of the file show that you purchased a portable gaseous oxygen system (E0430) on March 23, 2020 
from a non-Medicare provider. Medicare guidance says to receive payment for covered Medicare items or 
services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an 
unassigned claim), a provider or supplier must be enrolled in the Medicare program. 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. Furthermore, the rules say that only 
rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily non-covered. The 
purchase of the same DME equipment would be considered not medically reasonable and necessary because it 
serves the same purpose as equipment already available to you. Therefore, we decided that the Plan does not 
have to pay for portable gaseous oxygen system (E0430) purchased on March 23, 2020 from a non-Medicare 
provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on March 18, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 services provided to the enrollee on March 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the ambulance 
transportation required was due to directly to his premature discharge from the hospital by the doctor and his 
worsening disease. The Plan denied your request. The Plan says you were charged this cost sharing 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 $200 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $200 for these 
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 the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy evaluation provided on 
March 3, 2020. 
 
You asked the Plan to waive the copayment for the physical therapy evaluation. You say that you paid a $250 
at the time of the surgery. You say you should not be charged an additional $35 copayment. The Plan denied 
your request. The Plan says you have been charged the correct cost sharing 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). Your contract with the Plan clearly says that you must pay a $35 
copayment for each in-network Medicare-covered physical therapy and speech-language therapy visit.  
 
You have been asked to pay a $35 copayment for the physical therapy evaluation. The physical therapy 
evaluation falls within Outpatient Rehabilitation Services benefit category. The record shows you were 
charged separately for the physical therapy evaluation. 
 
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 physical therapy evaluation provided on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 9, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the optometry services (92014, 92015 and 92250). You say that you would like 
reconsideration because you have not been reimbursed for these services. The Plan denied your request. The 
Plan says vision services must be received from a participating provider in order to be covered by the Plan. 
 
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 on March 9, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on February 11, 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. The 
Plan says that the member's Primary care Physician did not refer these 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 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 February 11, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 3, 2020. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says The Plan says this is an administrative determination for coding and is not based on 
clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use 
of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the claim is missing the main code 
and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of 
this claim have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing 
provided to the enrollee on March 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot x-ray rendered on December 28, 2019.
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 73620 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 73620 and 73630. Code 73620 is a column II code with a modifier indicator of 1 when billed with column I code 73630. Code 73620 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 foot x-ray rendered on December 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for routine foot care visits provided from April 11, 2019 to
August 19, 2019.
You asked the Plan to pay for routine foot care. You say that your provider is not always able to obtain prior
authorization and sees the enrollee in good faith. The Plan denied your request. The Plan says the denial of
payment for these services is correct, because these services were routine foot care and are not a 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
routine foot care have not been met. Therefore, we decided that the Plan does not have to pay for routine foot
care visits provided from April 11, 2019 to August 19, 2019.