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

 
We decided that the Plan does not have to pay for the medical services provided on January 2, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that incorrect plan information was given  upon 
registration. The Plan denied your request. The Plan says the enrollee's plan requires the utilization of network 
providers, and authorization for certain 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 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 services at issue. We 
found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the 
Plan does not have to pay for the medical services provided on January 2, 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 the high frequency chest wall oscillation device. 
 
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. The rules say that a supplier must have an order from the treating 
physician before dispensing any DMEPOS item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 high frequency chest wall oscillation device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased January 16, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that you bought this policy because it included 
additional benefits for hearing, vision and dental services. You paid $2,300 for the hearing aids and 
examination so please processes accordingly. The Plan denied your request. The Plan says this claim processed 
correctly per the plan benefits. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from an in-network provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids purchased January 16, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on May 17, 2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges 
because the visit was only 26 minutes long and you were diagnosed without an X-ray. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 
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 emergency care provided on 
May 17, 2020.  
 
We note your complaint that you were diagnosed without an X-ray. Your complaint is a grievance that must be 
answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided on February 25, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for specialist services. You say that you do not agree with this denial of payment. 
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 specialist services provided on February 25, 2019 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 18, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the lab performed the tests that were ordered by 
the referring physician. The Plan denied your request. The Plan says the enrollee's plan requires utilization of 
network providers, and authorization for certain 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 provider in this case is not a network provider with the Plan. The ordering provider is also 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 services at issue. We found no exception that would require the Plan 
to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on May 18, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 6, 2020. 
 
You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there 
was a more effective therapy to treat the enrollee's advanced cancer. The Plan denied your request. The Plan 
says there is a more appropriate code to describe the services provided. 
 
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 the claim provided was not billed per Medicare guidance. 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 the Guardant360 testing provided on May 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
April 2, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation did not include any itemized shipping invoice or valid physician 
order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery is support medical necessity for the supplies provided in 
this case. There is not a valid itemized shipping/billing invoice so the billed code cannot be verified. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
April 2, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vertebral corpectomy (63081) provided October 8, 2020. 
 
You asked the Plan to pay for the vertebral corpectomy. You say that please find the attached medical records. 
Your physician assisted on this surgery for procedures 1, 4, 5 and performed the exposure. The Plan denied 
your request. The Plan says the records do not support the services 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 63081 is vertebral corpectomy (vertebral body resection), 
partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s) 
 
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 the Vertebral corpectomy. Our reviewer says 
that there is insufficient documentation to corroborate the services and confirm Medicare coverage has been 
met. Our physician reviewer found the documentation submitted was carefully reviewed, and, does not meet 
criteria.  The operative report, did not document that at least half of the vertebral body was resected.  The 
addendum was then reviewed, and also, does not meet criteria.  The addendum documents "Regarding the 
partial corpectomies at C4 and C5, at least approximately 50% of the vertebral body was resected inferiorly at 
C4 and superiorly at C5".  The addendum fails to clearly support that at least half of the vertebral body was 
resected. Therefore, this code cannot be verified. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Vertebral corpectomy have not been met. Therefore, we decided that the 
Plan does not have to pay for the vertebral corpectomy (63081) provided October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 18, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had a sprained ankle and was 
given crutches. The Plan denied your request. The Plan says the services require prior authorization, which 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 file shows that the enrollee was seen 3 days after a fall. The documentation does not show the services 
were urgent or emergent. 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 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 the medical services provided on December 18, 2019 by an 
out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram provided on May 26, 2020. 
 
You asked the Plan to pay for the electrocardiogram, routine ECG with at least 12 leads; interpretation and 
report only (93010). You say that the Plan should pay this claim. The Plan denied your request. The Plan says  
the services are included in the PPS payment for the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnostic testing and services as part of a pre-
operative examination and/or outpatient procedure or surgery, are not separately covered apart from the 
Medicare prospective payment.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the electrocardiogram, routine ECG with at least 12 leads; interpretation and report only (93010). 
have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram provided 
on May 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on May 6, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy for the enrollee's condition. The Plan denied your request. 
The Plan says the denial of payment for this testing is correct, because this testing was not billed with the 
appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT 
code 81479 for date of service May 6, 2020.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
Guardant360 testing provided on May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on March 24, 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 procedure code 36246 is not supported. 
 
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 36246 is selective catheter placement, arterial system; 
initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family. 
 
We find that CPT code 36246 is not supported in the medical record. Specifically, the operative report does not 
include documentation of a selective catheter placement into the arterial system. 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 surgical services rendered on March 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 7, 2020. 
 
You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there 
was a more effective therapy to treat the enrollee's advanced cancer. The Plan denied your request. The Plan 
says coverage of comprehensive genomic profile testing is limited to one test per specimen. 
 
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 the claim provided does not show that the testing was billed according to coding guidelines. 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 the Guardant360 testing provided on April 7, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the emergency room services provided on 
January 7, 2020. 
 
You asked the Plan to waive the copay for the services provided. You say that the doctor did not do anything. 
The Plan denied your request. The Plan says the copay was applied based on the services rendered. 
 
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 $90 
copay for Medicare-covered emergency room visits.  
 
You have been asked to pay a $90 copay for your visit to the emergency room. The services fall within the 
emergency 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 copay for the emergency room services 
provided on January 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on January 14, 2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the testing is 
not a benefit for the diagnosis listed on the claim. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The documentation does not show that the gene panel testing was ordered to determine a specific diagnosis or 
treatment strategy. The test at issue in this appeal was requested for screening purposes. Medicare does not 
cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
testing provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on April 14, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physician 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 facility is also 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 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 physician services provided on April 14, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reimburse the full amount for the cleaning, bitewing x-rays, periodic oral 
evaluation, and 5 fillings provided from January 23, 2020, to March 10, 2020 by the out of network dentist. 
 
You asked the Plan to reimburse the full amount for the dental services. You say that you were advised that the 
dentist accepted your insurance. You say that you paid for the services up front with the assumption that you 
would be reimbursed. The Plan denied your request. The Plan says that there is a 50% coinsurance for 
comprehensive dental services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not substantiate their claim that the one filling for tooth # 19 had in 
fact exceeded the frequency limit. Therefore, we decided that the Plan has to reimburse the full amount for the 
cleaning, bitewing x-rays, periodic oral evaluation, and 5 fillings provided from January 23, 2020, to March 10, 
2020 by the out of network dentist.  
 
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 pay for the neuromuscular stimulator, electronic shock unit provided 
to the enrollee. 
 
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that there are no clinical notes from the member?s primary health provider. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the neuromuscular 
stimulator, electronic shock unit provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (98941 and 99202). 
 
You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration because 
you did not know this provider did not honor your insurance. The Plan denied your request. The Plan says the 
out-of-network benefit for your plan is $1,500 and has not been met. 
 
The Plan must follow Medicare rules. The Plan offers out-of-network benefits for chiropractic services under 
specific circumstances. The rules say that after your yearly deductible is met, you pay 50% for each Medicare-
covered visit. Non-Medicare covered routine visits and x-rays performed by a chiropractor are not covered out-
of-network. 
 
The records show that your out-of-network deductible has not yet been met. Additionally, routine services have 
been denied because these are not a covered out-of-network benefit. Therefore, we decided that the Plan does 
not have to pay for chiropractic services (98941 and 99202).