Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit services provided on January 6, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the rest home visit services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 rest home visit services provided on January 6, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the physician service copayment for services 
provided on March 11, 2020. 
 
You asked the Plan to reimburse you for the physician service copayment. You say that you were told you 
would have zero charges or copayments. The Plan denied your request. The Plan says they will reimburse you 
for the refraction charge, since it is unclear in the Evidence of Coverage that refraction is not covered, but you 
have been charged the copayment correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers Vision Care physician services with a $20 copayment. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that you were charged the 
physician service copayment correctly. Therefore, we decided that the Plan does not have to reimburse you for 
the physician service copayment for services provided on March 11, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 24, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the rest home visit (99336). You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says these services were available to be 
provided in network and were not authorized as required. 
 
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 February 24, 
2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT 77067 provided on April 22, 2019. 
 
You asked the Plan to pay for CPT 77067. 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  is Screening mammography, bilateral (2-view study of 
each breast), including computer-aided detection (CAD) when performed. 
 
We find that CPT code  is not supported in the medical record. Specifically, the file shows that the Plan paid 
for this procedure on another claim for the same date of service. There was only one Imaging report provided 
indicating this service was only provided once. Based on this information, we decided that Medicare rules for 
coverage of CPT 77067 have not been met. Therefore, we decided that the Plan does not have to pay for CPT 
77067 provided on April 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assisted living care provided on March 20, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for assisted living care. You say that it is the hospital staff's responsibility to 
obtained prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained 
by the facility or the provider. The Plan says that the referring provider is out-of-network. 
 
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 assisted living care provided on March 20, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental consultation (D9310) provided May 13, 2020. 
 
You asked the Plan to pre-approve the dental consultation. You say that the service was medically necessary. 
The Plan denied your request. The Plan says this service is not a covered service. 
 
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 pre-approve a 
dental consultation (D9310) provided May 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 00160 provided on November 
30, 2019. 
 
You asked the Plan to pay for the anesthesia 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. 
 
In this case, the CPT Code Manual definition of code 00160 is anesthesia for procedures on nose and accessory 
sinuses; not otherwise specified. 
 
We find that CPT code 00160 is not supported in the medical record. Specifically, this service was billed with 
modifier 78. According to the Medicare Physician Fee schedule, code 00160 is listed with 'XXX' for global 
surgery so the global concept does not apply to the code. This means that modifier 78 is not appropriate for 
anesthesia codes. Based on this information, we decided that Medicare rules for coverage of the anesthesia 
services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services 
coded 00160 provided on November 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit (99336) provided on January 20, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for an OON rest home visit. You say that the facility was responsible for 
authorization. The Plan denied your request. The Plan says this was not authorized. 
 
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 rest home visit (99336) provided on January 
20, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on June 27, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that with the ambulance medics emergency 
assistance they resolved the matter. 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 June 27, 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 June 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on December 18, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the imaging services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide 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 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 imaging services provided on December 18, 
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit services provided on February 25, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the rest home visit services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 rest home visit services provided on February 
25, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable oxygen equipment (E1392) provided October 12, 
2019. 
 
You asked the Plan to pay for the portable oxygen equipment. You say that the portable oxygen is medically 
necessary. The Plan denied your request. The Plan says portable oxygen equipment is only covered when 
rented. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B (Medical Insurance) covers the rental 
of oxygen equipment and accessories.   
 
 
We looked the file, and Medicare rules. Portable oxygen equipment is covered only when rented. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for portable oxygen equipment (E1392) provided October 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
February 28, 2020 to March 4, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford the 
charges. The Plan denied your request. The Plan says 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment per day for days 1-6 for inpatient hospital care.  
 
You had an inpatient hospital stay from February 28, 2020 to March 4, 2020. Therefore, you are responsible to 
pay a $275 copayment for days 1-5 (February 28, 2020 to March 3, 2020). $275 (copayment) x 5 (inpatient 
days) = $1,375.  
 
You have been asked to pay the total copayment amount of $1,375 for an inpatient hospital stay. An inpatient 
hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided from February 28, 2020 to March 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core buildup, including any pins 
when required (D2950) provided on February 26, 2020. 
 
You asked the Plan to pay for the crown and core buildup. You say that you thought the Plan would pay up to 
$1,000 for your dental services. You also say that dental coverage should be any work completed by the dentist 
for the welfare of the patient. The Plan denied your request. The Plan says the total cost share amount of 
$647.50 was applied correctly. The Plan also says that you are responsible for 50% of the allowed amounts for 
these 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 are responsible for a 50% 
coinsurance. Therefore, we decided that the Plan does not have to pay for the crown (D2740) and core buildup, 
including any pins when required (D2950) provided on February 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on February 29, 
2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says inpatient level of care was not medically necessary. 
 
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 review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. 
 
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 on February 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for introduction/injection of anesthetic agent (64450) ultrasonic 
guidance for needle placement imaging supervision and interpretation (76942) provided March 4, 2020. 
 
You asked the Plan to pay for the injection services. You say that this claim was denied as 
experimental/investigational. The EOB did not give adequate information to establish the accuracy of this 
decision. The Plan denied your request. The Plan says this service is considered as experimental, 
investigational, cosmetic or not generally recognized according to professional standards of safety and 
effectiveness for diagnosis care or treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay 
for introduction/injection of anesthetic agent (64450) ultrasonic guidance for needle placement imaging 
supervision and interpretation (76942) provided March 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the measurement of post-voiding residual urine and/or 
bladder capacity by ultrasound services coded 51798 provided on February 22, 2020. 
 
You asked the Plan to pay for the measurement of post-voiding residual urine and/or bladder capacity by 
ultrasound services. You say that you would like the plan to reconsider their denial. The Plan denied your 
request. The Plan says the services coded 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. 
 
In this case, the CPT Code Manual definition of code 51798 is measurement of post-voiding residual urine 
and/or bladder capacity by ultrasound, non-imaging. 
 
We find that CPT code 51798 is not supported in the medical record. Specifically, code 51798 has a PC/TC 
indicator of 3, identifying a technical component only code. When a physician or other qualified health care 
professional provides the equipment to perform the service or procedure in a facility place of service, only the 
facility may be reimbursed for the Technical Component of the service or procedure. Based on this 
information, we decided that Medicare rules for coverage of the measurement of post-voiding residual urine 
and/or bladder capacity by ultrasound services have not been met. Therefore, we decided that the Plan does not 
have to pay for the measurement of post-voiding residual urine and/or bladder capacity by ultrasound services 
coded 51798 provided on February 22, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on August 22, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for outpatient services. You say that the patient was in an assisted living facility. 
You say that the patient did not have an option of provider. 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 outpatient services provided on August 22, 2019 
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 December 27, 2019 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that it is the facility's responsibility to obtain 
prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the 
provider or facility. 
 
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 December 27, 
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) and x-ray (72114) provided on April 
20, 2020. 
 
You asked the Plan to pay for an office visit  and x-ray. You say that this provided is certified. The Plan denied 
your request. The Plan says this provided is not eligible for Medicare. 
 
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 at issue is not enrolled in Medicare. Based on this 
information, we decided that Medicare rules for coverage of an office visit  and x-ray have not been met. 
Therefore, we decided that the Plan does not have to pay for an office visit (99214) and x-ray (72114) provided 
on April 20, 2020.