Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collarbone x-ray rendered. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The plan must follow Medicare rules. The rules say that anatomical 
modifiers are required for procedures performed on different anatomical sites. 
 
We looked at the file and Medicare rules. The provider billed procedure code 73000 without a required 
anatomical modifier. 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 collarbone x-ray rendered.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided by a participating 
provider on May 26, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that you are being over-charged. The Plan 
denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for outpatient diagnostic tests/radiological diagnostic services.  
 
You have been asked to pay a $150 copayment for each MRI. The total amount you are being asked to pay is 
$450 ($150 x 3 MRIs = $450). An MRI falls within the outpatient diagnostic tests/radiological diagnostic 
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 copayment for an MRI provided by a 
participating provider on May 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography services provided to the enrollee on December 
10, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the units of service exceed the allowed number of units of 2 in 1 day. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 75898 is not supported in the medical record. Specifically, this code is being reported 
with more than the maximum amount of units allowed. 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 angiography services provided to the enrollee on December 10, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient psychiatric services provided from May 27, 2020, through 
May 30, 2020. 
 
You asked the Plan to pay for the inpatient psychiatric services. You say that the inpatient psychiatric services 
provided were medically necessary for the enrollee. The Plan denied your request. The Plan says that the 
inpatient psychiatric services provided were not medically necessary and were not prior authorized. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 these services. Our reviewer says that the 
inpatient psychiatric services provided were medically necessary. Our physician reviewer found that the patient 
was admitted for the acute inpatient psychiatric hospitalization on May 26, 2020 with Schizophrenia Paranoid 
Type. Based upon review of the records provided, it was expected that this enrollee would improve in a 
reasonable period of time as he did have dangerousness to self and others, auditory but no visual hallucinations, 
delusions and was showing any behavioral issues. It did appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care as he did have 
dangerousness to self and others, perceptual disturbance including auditory hallucinations.  
The health plan's denial of inpatient psychiatric services appears inappropriate.  
 
 
This enrollee did appear to require inpatient mental health treatment as he was a danger to himself and others 
and was showing auditory hallucinations. It did appear that active treatment was taking place. It did appear that 
the services were reasonably expected to improve the patient's condition or was for the purpose of a diagnosis. 
An individualized treatment plan could not be identified; however, the entire record was not provided. It did 
appear that the records were supervised and evaluated by a physician. Based upon review of the records 
provided, the admission of this patient does meet the criteria for acute inpatient mental health treatment as this 
patient was shown to be a danger to himself and others while showing perceptual disturbance including 
auditory hallucinations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the inpatient psychiatric services provided from May 27, 2020, through May 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe durable medical equipment provided on February 21, 2019.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says proof of payment has not been received.The Plan must follow Medicare rules. Medicare rules say that sufficient information must be furnished to determine whether payment is due. We looked at the file and Medicare rules. The records provided do not include a receipt, or other valid proof of payment. 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 forthe durable medical equipment provided on February 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation care provided on March 25, 2020, by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the observation care. You say that the services provided were medically 
necessary. 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 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 observation care provided on 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 pay for outpatient services provided on July 28, 2020. 
 
You asked the Plan to pay for the outpatient services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
outpatient services. 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 outpatient services provided on July 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-ray rendered on June 3, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The plan must follow Medicare rules. The rules say that anatomical 
modifiers are required for procedures performed on different anatomical sites. 
 
We looked at the file and Medicare rules. The provider billed procedure code 73562 without a required 
anatomical modifier. 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 knee x-ray rendered on 
June 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 19, 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 screening tests are not covered. 
 
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 test at issue in this appeal, A1c testing, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on 
June 8, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that you were unaware the provider 
was out-of-network. The Plan denied your request. The Plan says services must be rendered in-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 the chiropractic manipulative treatment (98941) 
provided on June 8, 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 an oxygen concentrator (E0431, E1390) provided on 
December 8, 2018. 
 
You asked the Plan to pay for an oxygen concentrator. You say that this was originally mailed timely. The Plan 
denied your request. The Plan says this was not received timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for an oxygen concentrator was not filed until June 26, 2020. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for an oxygen concentrator (E0431, E1390) provided on December 
8, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure (D1999) and complete maxillary 
denture (D5110) provided on July 21, 2020. 
 
You asked the Plan to pay for the preventive procedure and complete maxillary denture. You say that you were 
not informed initially that your insurance would not cover the bill. You also say that you were advised at a later 
appointment that you would have to pay out of pocket. The Plan denied your request. The Plan says your plan 
does not provide benefits for the preventive procedure. The Plan also says that the calendar year maximum has 
been reached. 
 
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, preventive procedure (D1999) is not 
among those covered under this benefit. The Plan also offers a $1,000 combined allowance for supplemental 
preventive and comprehensive services. The contract says that after your annual maximum benefit maximum 
has been met, you are responsible for the full charges of any additional dental services. The record shows that 
you met the annual allowance while processing this claim for the July 21, 2020 date of service and your annual 
allowance has been exhausted. Therefore, we decided that the Plan does not have to pay for the preventive 
procedure (D1999) and complete maxillary denture (D5110) provided on July 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on April 12, 2020. 
 
You asked the Plan to pay for the services provided. You say that the best practice medical option was to 
protect the less severely ill from being exposed to Covid-19. The Plan denied your request. The Plan says the 
ambulance benefit without transport is not payable. 
 
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 April 12, 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 ambulance services provided on April 12, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan provided. 
 
You asked the Plan to waive the copayment for a duplex scan. You say that you disagree with the charges 
because this was a preventative service. 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 $160 
copayment for each covered diagnostic procedure or test.  
 
You received a duplex scan. A duplex scan is not considered a preventative procedure. 
Therefore, you are responsible to pay the $160 copayment.  
 
You have been asked to pay a $160 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe BiPAP and accessories provided on March 25, 2020.You asked the Plan to waive the coinsurance forthese items. You say that these charges are fraudulent.The Plan denied your request. The Plan says that the claim processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all costsharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Durable medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for these items. These items fall within the Durable medical equipment (DME) and related 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 coinsurance forthe BiPAP and accessories provided on March 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Vesiculectomy (55650) provided March 18, 2020. 
 
You asked the Plan to pay for the Vesiculectomy. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the documentation 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 55650 is Vesiculectomy, any approach. 
 
We find that CPT code 55650 is not supported in the medical record. Specifically, the records provided do not 
document that this procedure was a separate, distinct procedure from the primary procedure. Based on this 
information, we decided that Medicare rules for coverage of the Vesiculectomy have not been met. Therefore, 
we decided that the Plan does not have to pay for a Vesiculectomy (55650) provided March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient office visit provided. 
 
You asked the Plan to pay for the new patient office visit. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the enrollee had an office visit within the past 3 years and therefore not a 
new patient. 
 
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 99204 is Office or other outpatient visit for the evaluation 
and management of a new patient. 
 
We find that the enrollee received new patient services from the same provider on December 23, 2016. Based 
on this information, we decided that Medicare rules for coverage of the new patient office visit have not been 
met. Therefore, we decided that the Plan does not have to pay for the new patient office visit provided.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on May 17, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you were not given a choice. 
You say that you were just put into the ambulance and transported to the second hospital. The Plan denied your 
request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for ambulance services.  
 
You have been asked to pay a $200 copayment for an ambulance trip. Since an ambulance trip was provided, 
the correct copayment has been applied. An ambulance trip falls within the ambulance 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 copayment for an ambulance trip provided by a participating 
provider on May 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient (99214) 
provided on June 2, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient. You say that you were not 
aware the visit was considered OON. 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 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 established patient office or other outpatient 
(99214) provided on June 2, 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 a specialist visit provided on June 26, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges 
because the doctor came in to discharge you and you feel that you should not owe a copayment to see a 
physician at the hospital. 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 $35 
copayment for each specialist visit.  
 
The record shows that you were approved for observation level of care. Therefore, you are responsible to pay 
the $35 copayment for a specialist visit provided on June 26, 2020.  
 
You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the outpatient 
hospital 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 copayment for a specialist visit 
provided on June 26, 2020.