Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments foroutpatient rehabilitation services provided from April 15, 2020, to May 13, 2020.You asked the Plan to waive the copayments foroutpatient rehabilitation services. You say that you were trying to save the insurance money and disagree with the copayment charges.The Plan denied your request. The Plan says the claims were processed correctly,and you are being charged the correct amount.Therules 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 rehabilitation services. You received outpatient rehabilitation services from April 15, 2020, to May 13, 2020 for a total of 3 visits. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40 (copayment) x 3 (PT visits) = $120. You have been asked to pay the total copayment amount of $120 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation services 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 copayments foroutpatient rehabilitation services provided from April 15, 2020, to May 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided  on January 29, 2020, through March 
25, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for an office visit. 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 by the facility 
or the provider; therefore, payment has been correctly denied. 
 
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 an office visit provided  on January 29, 2020, 
through March 25, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit you had on April 16, 
2020. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you should not have to pay 
this copayment because they didn't treat you--they just sent you to the emergency room. The Plan denied your 
request. The Plan says you were evaluated by urgent care staff, so this copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $55 
copayment for urgent care visits.  
 
You have been asked to pay a $55 copayment for the urgent care visit. Medical records from this visit indicate 
that you were evaluated by urgent care staff curbside.  The records show that you presented with a nosebleed 
and they reviewed your medications with you.  In addition, the records show that the evaluating staff reviewed 
your symptoms with you prior to advising you to see care at the emergency room. This copayment applies 
regardless of the extent of services received. 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 urgent 
care visit you had on April 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the 
out of network (OON) provider on April 21, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service 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 this service. Therefore, we decided that the Plan does not 
have to pay for the domiciliary or rest home visit (99335) rendered by the out of network (OON) provider on 
April 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the oxygen concentrator and sales tax purchased on 
October 7, 2019. 
 
You asked the Plan to reimburse for the services. You say that you are requesting reimbursement of services 
rendered. The Plan denied your request. The Plan says the services received are not covered by Medicare. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Review of the file show that you 
purchased an oxygen concentrator and paid for sales tax on October 7, 2019. The rules say that only rented 
oxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily non-covered. 
Furthermore, Medicare does not reimburse separately for sales tax. Therefore, we decided that the Plan does 
not have to reimburse for the oxygen concentrator and sales tax purchased on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for specialist services provided on March 4, 
2020. 
 
You asked the Plan to waive the coinsurance for specialist services. You say that you disagree with the charges 
because the provider told you that they do not bill your insurance company and it is up to you. 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 45% 
coinsurance for out-of-network physician/practitioner services, including doctor's office visits.  
 
You received specialist services from an out-of-network provider on March 4, 2020. Therefore, you are 
responsible to pay your share of the out-of-network cost-sharing charges. The total allowed amount is $224.36 
and 45% of that is $100.97.  
 
You have been asked to pay the total coinsurance amount of $100.97 for specialist services. Specialist services 
fall within the physician/practitioner services, including doctor's office visits 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 specialist services provided on March 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy/immunotherapy (HCPCS S9338) 
provided to the enrollee on April 6, 2020. 
 
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 this is not covered by Medicare. 
 
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 S9338 is "Home infusion therapy, immunotherapy, 
administrative services, professional pharmacy services, care coordination, and all necessary supplies and 
equipment (drugs and nursing visits coded separately), per diem." 
 
We find that CPT code S9338 is not supported in the medical record. Specifically, current Physician Fee 
Schedule does not price the requested HCPCS Code. This code is not valid for Medicare purposes.  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 home infusion therapy/immunotherapy (HCPCS S9338) 
provided to the enrollee on April 6, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nerve conduction studies (95907) and needle 
electromyography (95885) provided on December 9, 2019. 
 
You asked the Plan to pay for the nerve conduction studies and needle electromyography. You say that you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the 
documentation submitted does 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 95907 is nerve conduction studies; 1-2 studies. 
 
The CPT Code Manual definition of code 95885 is needle electromyography, each extremity, with related 
paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited 
(List separately in addition to code for primary procedure). 
 
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 nerve conduction studies and needle electromyography. 
Our reviewer says that CPT codes 95907, 95885 26 and 99885 26 XU do not meet criteria for billing or 
reimbursement consideration. Our reviewer found the technical report did not include documentation to support 
CPT 95907.  Nerve conduction studies are not pedicle screw or direct root stimulation. Additionally, the 
documentation is insufficient to verify CPT 95885. 
 
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 nerve conduction studies and needle electromyography have not been met. 
Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95907) and needle 
electromyography (95885) provided on December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT Scan of the thorax (71250) provided on May 23, 2020. 
 
You asked the Plan to pay for the CT Scan. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says per NCCI PTP Coding Edits, code 71250 is a 
component of column 1 code 71260 and only code 71260 will be reimbursed. 
 
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, we have confirmed that code the CT 
Scan has a bundled relationship with code 71260 and cannot be paid as billed. This code cannot be paid as a 
separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for a CT Scan of the thorax (71250) provided on May 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ostomy supplies you received on 
November 16, 2019. 
 
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that since this was the provider's 
billing error, you should not have to pay additional cost sharing. The Plan denied your request. The Plan says 
the provider inadvertently charged the wrong number of units for the ostomy supplies when they first filed their 
claim.  They mistakenly only billed for 2 units when you were provided with 60 units.  The provider has fixed 
their billing to reflect the correct number of units of ostomy supplies you received (60).  Since you did receive 
60 units, you were appropriately assessed coinsurance for 60 units. 
 
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 prosthetic devices and related supplies.  
 
You have been asked to pay 20% coinsurance for 60 units of these ostomy supplies. Since you received 60 
units, it is only appropriate that you be charged coinsurance for 60 units, even if it was billed incorrectly 
initially. 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 ostomy supplies you received on November 
16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis, the knee orthoses and suspension sleeves provided on April 29, 2020.You asked the Plan to pay forthe lumbar-sacral orthosis (L0650), the knee orthoses (L1833) and suspension sleeves (L2397). You say that the enrollee's physician ordered the orthoses.The Plan denied your request. The Plan says the office visit did not show the ordering provider had diagnosed or treated the member for any issue in which a knee orthosis or lumbar-sacral orthosis was needed.The Plan must follow Medicare rules. The rules state that Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the enrollee in accordance with Medicare policies. You can find this in the Medicare Program Integrity Manual Chapter 3 -Verifying Potential Errors and Taking Corrective Actions, Section 3.3.2.4 entitled Signature Requirements.The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan confirmed with the enrollee that the braces were not needed or discussed at any visit.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis, the knee orthoses and suspension sleeves provided on April 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a bone biopsy provided on February 28, 
2020. 
 
You asked the Plan to waive the coinsurance for a bone biopsy. You say that you feel that the charges are too 
high. 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 20% 
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You received a bone biopsy on February 28, 2020. The allowed amount is $2,153.88 and 20% of that is 
$430.78.   
 
You have been asked to pay the total coinsurance amount of $430.78 for a bone biopsy. A bone biopsy falls 
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 a bone biopsy provided on 
February 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 26, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that you are appealing. 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 the ordering provider is also out-of-network with the Plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on February 26, 
2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110), oral evaluation (D0120), periapical 
x-ray (D0220), and an additional periapical x-ray (D0230) provided on May 8, 2020 by the out of network 
dentist. 
 
You asked the Plan to pay for the dental services. You say that you checked that your doctors were acceptable 
when you signed up for your plan. You also say that you were under the impression that you were covered to 
see your doctors. The Plan denied your request. The Plan says dental services that you receive from an out of 
network dentist 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 and the dental services you received are 
listed as covered, the dental provider is not a network provider. Dental services that you receive out of network 
are not covered. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110), oral 
evaluation (D0120), periapical x-ray (D0220), and an additional periapical x-ray (D0230) provided on May 8, 
2020 by the out of network dentist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (0054T) provided on May 8, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the codes listed in A57743 are non-covered.  
 
We looked at the file and Medicare rules. Per LCA A57743, code 0054T is non-covered. 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 the services (0054T) provided on May 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe outpatient hospital services provided on February 22, 2020.You asked the Planto pay forthe outpatient hospital services. You say that this must be paid by the plan.The Plandenied your request. The Plansaysin order to receive Medicare payment for these services, the claim must be billed correctly. For outpatient hospital care, payment is made based on the AIR when a claim is received with all charges listed on revenue code 0510. This claim was not billed according to the required format.The Plan must follow Medicare rules. Medicare rules say that IHS providers must billed outpatient hospital services on an 013X type of bill and include all AIR charges on a single line item with revenue code 0510.This claim was billed as a non-IHS provider claim and cannot be paid as billed.Therefore, we decided that the Plandoes not haveto pay forthe outpatient hospital services provided on February 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four gingival irrigations (D4921 x4) and bone 
replacement graft for ridge preservation (D7953) provided from April 27, 2020 to May 21, 2020. 
 
You asked the Plan to pay for the gingival irrigations and bone replacement graft. You say that without these 
procedures your jaw bone would have become infected. You also say that the dentist advised that these services 
were necessary. The Plan denied your request. The Plan says these services are not covered benefits under your 
dental plan. 
 
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 four 
gingival irrigations (D4921 x4) and bone replacement graft for ridge preservation (D7953) provided from April 
27, 2020 to May 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant-360? testing provided on May 1, 2020. 
 
You asked the Plan to pay for Guardant-360?. You say that you would like this claim processed in-network 
because you are the only service provider for this testing. The Plan denied your request. The Plan says 
Guardant-360?  testing requires the use of CPT code 81479 and the appropriate DEX Z identifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Guardant-360? have not been met. Per Medicare guidance, this testing requires the use of CPT 
code 81479. Therefore, we decided that the Plan does not have to pay for Guardant-360? testing provided on 
May 1, 2020.