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

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
January 7, 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 requested 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 out of network physician services provided to the enrollee on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on January 13, 
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 requested 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 January 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on May 7, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a 
physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 
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 drug testing rendered on May 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for thrombolysis (37195) provided on February 27, 2020. 
 
You asked the Plan to pay for the thrombolysis. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says CPT code 37195 has a Professional 
Component (PC)/Technical Component (TC) indicator of 5 per the January 2020 National Physician Fee 
Schedule. 
 
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 code 37195 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 37195 has a professional/technical indicator of 5. This means that payment may not be made by carriers 
for these services when they are provided to hospital inpatients or patients in a hospital outpatient department. 
In this case, CPT code 37195 has been reported with Place of Service code 21 for inpatient hospital.  Based on 
this information, we decided that Medicare rules for coverage of the thrombolysis have not been met. 
Therefore, we decided that the Plan does not have to pay for thrombolysis (37195) provided on February 27, 
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on February 18, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service is included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a practitioner visit provided on September 3, 2019. 
 
You asked the Plan to pay for practitioner visit. You say that your provider did not have the opportunity to 
obtain authorization from the Plan. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because this provider is out-of-network with the Plan and authorization was not obtained. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for a practitioner visit provided on September 3, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 25, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on March 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on December 10, 
2019. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, intraoral x-rays and
periodontal scaling and root planing provided on October 28, 2019.
You asked the Plan to pay for the comprehensive oral evaluation, intraoral x-rays and periodontal scaling and
root planing. You say that according to the EOC, code D4341 is covered at 50%. You say that the dentist is a
Plan provider. 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
comprehensive oral evaluation, intraoral x-rays and periodontal scaling and root planing provided on October
28, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Myocardial Nuclear Perfusion Imaging 
(78452) provided April 28, 2020. 
 
You asked the Plan to waive the copayment for the Myocardial Nuclear Perfusion Imaging. You say that the 
copayment should be waived. 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 $150 
copayment for Advanced Radiology.  
 
You have been asked to pay a $150 copayment for the Myocardial Nuclear Perfusion Imaging. The Myocardial 
Nuclear Perfusion Imaging falls within the Advanced Radiology 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 Myocardial Nuclear Perfusion Imaging (78452) provided April 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on March 9, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you went in for your yearly 
physical and should not be paying a $20 office charge. 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 $20 
copayment for a primary care physician.  
 
You have been asked to pay a $20 copayment for the office visit. The office visit falls within the Physician/ 
Practitioner services, including doctor's office visits benefit category. The medical record shows that in 
addition to the wellness visit, you and your doctor discussed chronic neck pain and benign prostatic hyperplasic 
with urinary retention. 
 
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 visit provided on March 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services (CPT 99223) provided to the enrollee on 
January 21, 2020. 
 
You asked the Plan to pay for the services. You say that the plan should reconsider payment. The Plan denied 
your request. The Plan says this is not reported with the correct place of service. 
 
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 99223 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires at least 2 of these 3 key components: A 
detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting 
problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient 
and/or family." 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, these services are inpatient, 
so they should be reported with a place of service 11. 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 inpatient services (CPT 99223) provided to the enrollee on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of an interlaminar/interspinous process 
stabilization device. 
 
You asked the Plan to pre-approve the device. You say that you would like reconsideration because this device 
is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says 
this device is experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this device is experimental and more research is needed to show its safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the insertion of an interlaminar/interspinous process stabilization device.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating
hospital on March 10, 2020.
You asked the Plan to waive the copayment for an ultrasound. You say that you were told that you would have
to pay $50, not $100. 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 $100
copayment for outpatient diagnostic tests/in-network/diagnostic tests/outpatient hospital facility.
You have been asked to pay $95.47 which is less than your copayment amount of $100 for an ultrasound. This
ultrasound was provided in an outpatient hospital; therefore, the correct copayment has been applied. An
ultrasound falls within the outpatient diagnostic tests/in-network/diagnostic tests/outpatient hospital facility
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 ultrasound provided by a
participating hospital on March 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture and complete mandibular 
denture provided on March 14, 2020. 
 
You asked the Plan to pay for the complete maxillary and mandibular dentures. You say that you were 
informed by the dental office that these services were covered. The Plan denied your request. The Plan says 
these services are not covered. 
 
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 
complete maxillary denture and complete mandibular denture provided on March 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hospital bed, total electric (head, foot and height adjustments), with any type side rails, with mattress (E0265), for the enrollee.
You asked the Plan to pre-approve the total electric bed. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules say that a total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve hospital bed, total electric (head, foot and height adjustments), with any type side rails, with mattress (E0265), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for smoking and tobacco use cessation counseling (99406) and initial hospital care (99223) provided on December 11, 2019 through December 13, 2019.
You asked the Plan to pay for the smoking and tobacco cessation counseling and initial hospital care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 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 99406 is Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes. The CPT Code Manual definition of code 99223 is Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. 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 smoking and tobacco cessation counseling and initial hospital care. Our reviewer says that CPT code 99406 does not meet criteria for billing or reimbursement consideration. The documentation did not support this CPT code. The recorded diagnosis is unrelated to Behavior Change Interventions, Individual services, Smoking and tobacco use cessation counseling visit. Our reviewer found CPT code 99223 does not meet criteria for billing or reimbursement consideration. it is inappropriate to bill an evaluation and management code within the time frame of the global surgical package unless it is a significant identifiable evaluation and management 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 smoking and tobacco cessation counseling and initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay for smoking and tobacco use cessation counseling (99406) and initial hospital care (99223) provided on December 11, 2019 through December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a heart/lung machine provided on March 6, 2020.
You asked the Plan to pay for the heart/lung machine services. You say that these services should be paid as it takes time to set up this machine and the perfusionist has to remain in the operating room throughout the procedure. The Plan denied your request. The Plan says this is not separately payable.
The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. Although these services may be appropriate, they are non-physician services and payment for them is made to the hospital which must then furnish these services either directly or under arrangements. As such, separate Medicare payment cannot be made for the services at issue. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a heart/lung machine provided on March 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating
provider on February 11, 2020.
You asked the Plan to waive the copayment for lab work. You say that this should have been included in your
other 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 $40
copayment for outpatient diagnostic tests/in-network/lab/outpatient hospital.
You have been asked to pay a $40 copayment for lab work. The correct copayment has been applied to the
services that were provided. Lab work falls within the outpatient diagnostic tests/in-network/lab/outpatient
hospital 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 lab work provided by a
participating provider on February 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulators (TENS) 
device. 
 
You asked the Plan to pay for the TENS device. You say that please be advised that these services are covered 
under the plan's medical policy, therefore this claim denied in error. The Plan denied your request. The Plan 
says the enrollee was not enrolled in a clinical trial and does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the TENS device have not been met. Therefore, we decided that the Plan does not have to pay for 
the transcutaneous electrical nerve stimulators (TENS) device.