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

We decided that the Plan has to pay for physician's services for an ECG provided during an emergency room visit on March 13, 2020.
You asked the Plan to pay for the physician's services for an ECG. You say that you were traveling and were 200 miles away from home when you could not breathe and you needed a breathing treatment. You say you went to the nearest urgent care facility and they did not have the proper filtration system and sent you to a hospital emergency room where you received care. The Plan denied your request. The Plan says that the provider is not in-network and there is no authorization on file,
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health. We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for physician's services an ECG provided during an emergency room visit on March 13, 2020.
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes 
(CPT Code 99239) provided to the enrollee on January 15, 2020. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the member was enrolled in hospice at the time of services. The Plan states per Medicare 
guidelines, the member's services should be billed under Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. The 
member was enrolled in hospice from October 16, 2019 through March 13, 2020. Therefore, we decided that 
the Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT Code 
99239) provided to the enrollee on January 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on December 27, 2019.
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 does not indicate services are necessary for treatment of the enrollee's condition.
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 a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on December 27, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full hereditary cancer panel provided on December 14, 
2019. 
 
You asked the Plan to pay for the testing services. You say that the enrollee has a personal history of stomach 
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 items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. In this case, there were insufficient records provided to show the 
results of this testing would be used to determine a specific diagnosis or determine a specific treatment strategy 
for disease or illness present in the enrollee at the time of service. This testing is not covered for screening 
purposes. 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 full hereditary cancer panel provided on 
December 14, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out of network 
(OON) provider on February 10, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were provided 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 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 laboratory services rendered by the out of network (OON) provider on  
February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the anticoagulant management provided on
March 3, 2020.
You asked the Plan to waive the copayment for the anticoagulant management. You say that you do not have a
deductible and you were told that blood tests were free. 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 each Medicare-covered specialist visit. For this date of service, you have been asked to pay the
allowed amount of the claim because this amount is less than the $20 copayment for the anticoagulant
management.
You have been asked to pay a $12.49 copayment for the anticoagulant management. The anticoagulant
management falls within the "Physician/Practitioner services, including doctor's office visits" benefit category.
The record shows that the anticoagulant management is considered a cardiology physician service.
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 anticoagulant management provided on March 3, 2020.
Appeal type: Imaging
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 the portable x-ray services (R0070, 71046 and Q0093) provided on February 26, 
2020.. You say that you would like reconsideration because these services do not require authorization. The 
Plan denied your request. The Plan says an approved authorization was not obtained prior to the services being 
rendered. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on January 6, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network 
deficiency for these 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 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 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 to the enrollee by an out-of-network provider 
on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of complications provided on February 5, 2020. 
 
You asked the Plan to pay for the treatment of complications. The Plan denied your request. The Plan says this 
service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
treatment of complications provided on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on October 21, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
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 asked our coding 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 services. Our reviewer says that the use 
of CPT codes 95941, 95938, 95955, 95909, 95885, 95999, is not supported by the records provided. Our 
coding reviewer found that the medical records provided do not include an intraoperative neuro-monitoring 
report, therefore the billed codes cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services provided on October 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675).
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service and PCDs billed by E0675 are not covered. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) and TENS device, four or 
more leads, for multiple nerve stimulation (E0730) provided to the enrollee from February 20, 2020 through 
February 22, 2020. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says they have concerns that this provider prescribes orthotics without a face-to-face evaluation of the 
enrollee. 
 
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 lumbar-sacral orthosis 
(L0650) and TENS device, four or more leads, for multiple nerve stimulation (E0730) provided to the enrollee 
from February 20, 2020 through February 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction provided on January 2, 2020. 
 
You asked the Plan to pay for the eye refraction. You say that this should not be denied as the provider was in-
network. The Plan denied your request. The Plan says the plan confirmed with the provider that the eye 
refraction was part of a follow up appointment, not a routine eye exam. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
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 eye refraction have not been met. The eye refraction you received on January 2, 2020 was not a 
routine eye exam. It was a follow up appointment. Your EOC states, eye refractions are a covered service 
during a routine eye exam performed by a network supplemental Routine Vision Care Provider. Therefore, we 
decided that the Plan does not have to pay for the eye refraction provided on January 2, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation rendered on November 
18, 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 the diagnosis is not valid. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were billed with invalid diagnosis 
codes and the claim is not valid as billed. The Plan has requested a corrected claim from the provider. 
Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation rendered on 
November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for repair prosthetic device, labor component, per 15 minutes (L7520), polishing/resurfacing of ocular prosthesis (V2624), scleral cover shell (V2627), fabrication and fitting of ocular conforme (V2628) and Prosthetic eye, other type (V2629) provided to the enrollee on February 27, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
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. Documentation submitted on appeal consists of duplicates of medical documents previously reviewed Healthcare Common Procedure Coding System (HCPCS) code V2627-LT (1 unit) remains not supported. The documentation submitted did not include a valid physician order. In addition, the documentation submitted did not include a proof of delivery; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Healthcare Common Procedure Coding System (HCPCS) code V2628-LT (1 unit) remains not supported. The documentation submitted did not include a valid physician order. In addition, the documentation submitted did not include a proof of delivery; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Healthcare Common Procedure Coding System (HCPCS) code V2628-LT (1 unit) remains not supported. The documentation submitted did not include a valid physician order. In addition, the documentation submitted did not include a proof of delivery; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Healthcare Common Procedure Coding System (HCPCS) code V2624-LT (1 unit) remains not supported. The documentation submitted did not include a valid physician order. In addition, the documentation submitted did not include a proof of delivery; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information.
Healthcare Common Procedure Coding System (HCPCS) code L7520 (10 units) remains not supported. The documentation submitted did not include a valid physician order. In addition, the documentation submitted did not include documentation of the time spent providing this service; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Therefore, we decided that the Plan does not have to pay for repair prosthetic device, labor component, per 15 minutes (L7520), polishing/resurfacing of ocular prosthesis (V2624), scleral cover shell (V2627), fabrication and fitting of ocular conforme (V2628) and Prosthetic eye, other type (V2629) provided to the enrollee on February 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that your neighbor had called for an ambulance
because they thought you were having a heart attack. You say that by the time the ambulance arrived, your
symptoms had all cleared up. You stated that the emergency responders checked you over and you could have
gone to the hospital, however you had already gotten your air back. You say that if you had gone to the
hospital, the Plan would have paid. You asked the Plan to reconsider their decision. The Plan denied your
request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on February 9, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on February 11, 2020. 
 
You asked the Plan to pay for genetic testing. You say that this testing was ordered by the treating physician to 
determine if there was a more effective therapy to treat the enrollee. 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 February 11, 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 February 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incision and drainage of an abscess (10061) provided on 
December 29, 2019. 
 
You asked the Plan to pay for the incision and drainage of an abscess. You say that this was billed correctly. 
The Plan denied your request. The Plan says there is a more appropriate code for the service 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 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 incision and drainage of an abscess. Our 
reviewer says that the use of this code is not supported. Our physician reviewer found the medical records 
provided do not include documentation to support an incision and drainage of abscess (eg, carbuncle, 
suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or 
multiple being performed on December 29, 2019, therefore this service 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 incision and drainage of an abscess have not been met. Therefore, we 
decided that the Plan does not have to pay for the incision and drainage of an abscess (10061) provided on 
December 29, 2019.