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

 
We decided that the Plan does not have to pay for the critical care services provided from January 25, 2020, to 
January 28, 2020. 
 
You asked the Plan to pay for the critical care services. The Plan denied your request. The Plan says the billed 
services are not supported. 
 
The Plan must follow Medicare rules. The rules say that critical care is not a service that is paid on a shift 
basis or a per day basis. Critical care service is paid on a time-based service provided on an hourly or fraction 
of an hour basis. For this reason, the documentation provided by the physician must include the amount of time 
in hours and minutes that is spent on providing critical care service. In this case, there is no evidence in the 
medical documentation to show the total time spent delivering critical care to the enrollee.  
 
 
 
 
 
 
 
 
Therefore, we decided that the Plan does not have to pay for the critical care services provided from January 
25, 2020, to January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services coded 99291 and 99292 provided on 
January 20, 2020. 
 
You asked the Plan to pay for the critical care 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 supported by the documentation. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
The CPT Code Manual definition of code 99292 is critical care, evaluation and management of the critically ill 
or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service). 
 
We find that CPT codes 99291 and 99292 are not supported in the medical record. Specifically, the 
documentation does not include the time spent providing these services. In addition, the additional time spent 
on critical care services billed was not supported by the documentation. Based on this information, we decided 
that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the 
Plan does not have to pay for the critical care services coded 99291 and 99292 provided on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for hemodialysis services received from 
January 2 to January 31, 2020. 
 
You asked the Plan to waive the coinsurance for hemodialysis services. You say that you cannot pay this 
charge. 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 outpatient dialysis treatments.  
 
You have been asked to pay $1,126.44, or 20% of the Plan-allowed amount $5,632.34, for hemodialysis 
services. Hemodialysis services fall within the "Services to treat kidney disease" 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 hemodialysis services received from January 2 to January 31, 2020.
Appeal type: Outpatient Mental Health
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 medical services. You say that you rely on the facility to get proper 
authorization.  You also say that these services were medically necessary and provided in good faith. The Plan 
denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 had network providers available 
who could have provided 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for hemoglobin A1C levels (83036) performed 
on May 3, 2018, and May 22 and November 20, 2019. 
 
You asked the Plan to waive the deductible for hemoglobin A1C levels. You say that you were informed by the 
Medicare website that as a prediabetic patient you would pay nothing for these laboratory services. The Plan 
denied your request. The Plan says that the Medicare website you reference discusses rules for Medicare Part B 
and not rules for Medicare Advantage. The Plan says that the correct cost-sharing was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The 
contract with the Plan says that there is a $200 deductible for medical services with a coinsurance.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category "Outpatient 
diagnostic tests and therapeutic services and supplies." The Plan has followed Medicare rules by clearly 
disclosing in the contract that there was a $200 deductible for medical services with a coinsurance. Medicare-
covered lab services are covered with 4% coinsurance. This cost sharing is a contractual obligation that had not 
yet been met at the time hemoglobin A1C levels were performed on May 3, 2018, and May 22 and November 
20, 2019. Therefore, we decided that the Plan does not have to waive the deductible for hemoglobin A1C levels 
(83036) performed on May 3, 2018, and May 22 and November 20, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on December 16, 2019 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the genetic testing services. You say that these services were medically necessary 
and you are the only provider that performs the Vectra DA test. The Plan denied your request. The Plan says 
unauthorized, non-plan care is not covered. 
 
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. 
 
Neither the provider in this case nor the ordering provider is 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 the genetic testing services 
provided on December 16, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) and 
electrocardiogram (93010) provided on June 25, 2018. 
 
You asked the Plan to pay for the emergency department visit and electrocardiogram. You say that you would 
like reconsideration because this Plan has processed and paid many claims in the past so you assumed this Plan 
was your primary. The Plan denied your request. The Plan says the claim must be paid by the primary 
insurance prior to the Plan paying their portion on the claim as your secondary insurance. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested the 
primary explanation of benefits from the provider. As the secondary insurer, the Plan cannot be held 
responsible for the emergency department visit and electrocardiogram until the primary insurer has denied the 
claim for these services. Therefore, we decided that the Plan does not have to pay for the emergency 
department visit (99285) and electrocardiogram (93010) provided on June 25, 2018.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 Plasma-Based Comprehensive Genomic 
Profiling testing provided on March 18, 2020 billed with multiple line items of different CPT codes. 
 
You asked the Plan to pay for the Guardant 360 testing as billed. You say that this should not be denied as 
experimental as this is a proven test which is supported for this patient. The Plan denied your request. The Plan 
says on review, it was found that no payment can be made for this testing because the provider is unbundling 
when there is a single CPT code which describes this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to report the Guardant360 testing, one 
unit of code 81479 should be reported with the appropriate DEX Z-code.  
 
As there is a single CPT code which describes this testing, the rule for coverage of this testing as billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 Plasma-Based 
Comprehensive Genomic Profiling testing provided on March 18, 2020 billed with multiple line items of 
different CPT codes.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 7 units of debridement (11047) provided on July 22, 
2019. 
 
You asked the Plan to pay for the 7 units of debridement. You say that the plan should pay this claim. The Plan 
denied your request. The Plan says 7 units of debridement are not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 7 units of CPT code 11047 are not supported in the medical record. The medical record supports 
9.55 total units of debridement. The Plan has paid for 4 units of debridement. Based on this information, we 
decided that Medicare rules for coverage of the remaining units of debridement have not been met. Therefore, 
we decided that the Plan does not have to pay for the 7 units of debridement (11047) provided on July 22, 
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual golf club fees. 
 
You asked the Plan to pay for the golf club fees. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan only covers driving 
range and green fees. 
 
The Plans rules for coverage of golf club benefits have not been met because the Plan only covers driving 
range and green fees. The requested annual fee includes more than just the driving range and green fees. 
Therefore, we decided that the Plan does not have to pay for the annual golf club fees.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost sharing for Part B drugs. We decided that the Plan does not 
have to waive the copayment for outpatient surgery.  
 
You asked the Plan to reduce the cost sharing for Part B drugs. You say that you previously were not charged 
this cost sharing. The Plan says that the cost sharing you are being charged is correct. 
 
We decided that the Plan has to reduce the cost sharing for Part B drugs.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Part B drugs.  
 
The Plan says that you must pay a copayment of $90.20 for Part B drugs. Based on the plan contract, however, 
you cannot be asked to pay more than 20% coinsurance for Part B drugs. The allowed amount for the Part B 
drugs is $90.20, resulting in a coinsurance amount of $18.04 ($90.20 x 20% = $18.04). Therefore, we decided 
that the Plan has to reduce the cost sharing from $90.20 to $18.04. 
 
We also decided that the Plan does not have to waive the copayment for outpatient surgery. 
 
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 $250 
copayment for outpatient surgery and Part B drugs. You have been asked to pay $58.87, which is less than your 
$250 copayment. Therefore, we decided that the Plan does not have to waive the copayment for outpatient 
surgery. 
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to adjust the copayment from $185 to $150 for the positron emission tomography 
(PET Scan) (78815) and fluorodeoxyglucose injection (A9552) provided on December 19, 2019. 
 
You asked the Plan to adjust the copayment for these services. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says that the copayment has been 
applied correctly to the services provided. 
 
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 $150 copayment for advanced imaging services and a $35 
copayment for basic radiological services.  
 
The Plan says you must pay a $185 copayment ($150 + $35) for the advanced imaging and basic radiological 
services provided. However, the Explanation of Benefits Statement does not show that code A9522 processed 
with an allowed amount; therefore, a copayment should not be applied to this service. We decided that the Plan 
has to adjust the copayment from $185 to $150 for the positron emission tomography (PET Scan) (78815) and 
fluorodeoxyglucose injection (A9552) provided on December 19, 2019.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 12, 
2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the services were medically 
necessary, given the enrollee's history and treatment options. The Plan denied your request. The Plan says the 
services were rendered by a non-contracted provider. The Plan also says that the services were rendered 
without the appropriate prior authorization. 
 
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 the subsequent nursing facility care provided on March 12, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 10, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you like this particular counselor and you feel 
comfortable with her.  You say that it should not be a problem for you to go to this provider. The Plan denied 
your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 10, 2020 
by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on 
November 21, 2019. 
 
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you disagree with 
the charges because the procedure was always covered by Medicare in the past. 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 $100 
copayment for nuclear medicine provided at a freestanding facility.  
 
You have been asked to pay a $100 copayment for myocardial perfusion imaging. Myocardial perfusion 
imaging 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 myocardial perfusion imaging provided on November 21, 
2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan provided on March 3, 2020. 
 
You asked the Plan to waive the copayment for a duplex scan. You say that you disagree with 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 $95 
copayment for diagnostic procedures and tests provided by a provider other than your primary care physician.  
 
You have been asked to pay a $95 copayment for a duplex scan. A duplex scan 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 a duplex scan provided on March 3, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Psychotherapy services provided on December 23, 2019 
by an out of network provider. 
 
You asked the Plan to pay for the Psychotherapy services (90832). You say that the hospital staff failed to take 
the proper steps to obtain authorization for the services. The Plan denied your request. The Plan says the Plan 
requires pre-approval of out of network services in non-emergent situations. 
 
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 Psychotherapy services provided on December 
23, 2019 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inhalation of nitrous oxide/analgesia provided on 
February 25, 2020. 
 
You asked the Plan to pay for the inhalation of nitrous oxide/analgesia. You say that the anesthesia was 
medically necessary with the service you received. The Plan denied your request. The Plan says this service is 
not a covered expense under your plan because it was provided with a root canal, which is not a covered 
procedure. 
 
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, anesthesia is only covered as needed 
with covered procedures. The record shows that you received a root canal, which is not a covered benefit. 
Therefore, we decided that the Plan does not have to pay for the inhalation of nitrous oxide/analgesia provided 
on February 25, 2020.