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

We decided that the Plan does not have to waive the copayment for a peripherally inserted central catheter (PICC)(C1751) and cataract surgery (66984) provided on March 4, 2021, to March 5, 2021.

You asked the Plan to waive the copayment for a PICC procedure and cataract surgery. You say that you need a PICC before surgery because you have bad veins that cannot be accessed in a cold operating room. You also say that you do not understand why you are being charged two copayments for your cataract surgery. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $225 copayment for each outpatient hospital services.

You have been asked to pay a $225 copayment for a PICC procedure and a $225 copayment for cataract surgery. The records show you had a PICC procedure in an outpatient department of a hospital on March 4th. The records also show you had cataract surgery in an ambulatory surgical center on March 5th. The EOC confirms $225 is the required copayment for each outpatient hospital service. A PICC procedure and cataract surgery fall 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 peripherally inserted central catheter (PICC)(C1751) and cataract surgery (66984) provided on March 4, 2021, to March 5, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology consultation and report (88321) provided October 1, 2020.

You asked the Plan to pay for surgical pathology services. You say that you have appended the appropriate modifier to indicate these are for additional, separate specimens. Please see attached documentation and reconsider for payment. The Plan denied your request. The Plan says the maximum frequency per day is 1 unit; therefore, 2 units remains not payable.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 88321 is 1. The MAI value for this code is 2. You billed 3 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of surgical pathology services have not been met. Therefore, we decided that the Plan does not have to pay for surgical pathology consultation and report (88321) provided October 1, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the Guardant 360 testing provided on

You asked the Plan to pay for the Guardant 360 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services rendered were not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

Review of the file shows that the Plan uses Local Coverage Determination (LCD) L38043 to support their denial. However, LCD L38043 is not valid for the provider's billing state of California. 

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 Guardant 360 testing. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has advanced non-small cell lung cancer. The enrollee has a diagnosis/condition that met criteria for the services rendered. 

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 Guardant 360 testing have been met. Therefore, we decided that the Plan has to pay for the Guardant 360 testing provided on

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for chest x-ray (71046) Set-up portable x-ray equipment (Q0092) transportation of portable x-ray equipment and personnel to home or nursing home (R0070) provided on November 11, 2020 by an out of network (OON) provider.

You asked the Plan to pay for portable x-ray services. You say that test reports are supposed to be furnished within 24 hours which do not allow you to have ample time to verify eligibility and process authorization beforehand. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for chest x-ray (71046) Set-up portable x-ray equipment (Q0092) transportation of portable x-ray equipment and personnel to home or nursing home (R0070) provided on November 11, 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 laboratory services coded 87486, 87541, 87581, 87640, 87496, 87498 and 87798 provided on May 5, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT codes 87486, 87541, 87581, 87640, 87496, 87498 and 87798 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 31. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 87541, 87581, 87640, 87496, 87498 and 87798 provided on May 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) wrist hand orthosis (L3916) provided November 16, 2020.

You asked the Plan to pay for the orthoses. You say that claim was denied as not medically necessary and insurance needs medical records to process the claim further. Please take it into consideration and process the claim for further payment. The Plan denied your request. The Plan says documentation indicates that the services are not necessary for treatment of the enrollee's condition.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) wrist hand orthosis (L3916) provided November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on February 15, 2021.

You asked the Plan to waive the copayment for the office visit. You say that you were told the doctor was in-network and there should be a $25 copayment. The Plan denied your request. The Plan says the copayment 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 $60 copayment for an out-of-network specialty care physician.

You have been asked to pay a $60 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show the provider is an out-of-network specialist. 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 office visit provided on February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure (CPAP) device (E0601) and supplies (E0562, A4604, A7030, A7035, A7038) provided on February 5, 2021.

You asked the Plan to waive the coinsurance for a CPAP device and supplies. You say that you were told by the provider, that the Plan would cover everything 100% and that your credit card would not be charged. You also say that you received an invoice telling stating your credit card was charged. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for each DME and related supplies.

You have been asked to pay a 20% coinsurance for a CPAP device and supplies. The EOC confirms 20% is the required coinsurance for each DME item. The records show you received six (6) DME items.

For the CPAP device (E0601), the allowed amount of the claim is $54, resulting in a coinsurance obligation of $10.80.
For the humidifier used with a CPAP device (E0562), the allowed amount of the claim is $174.81, resulting in a coinsurance obligation of $34.96.

For the tubing with heating element (A4604), the allowed amount of the claim is $46.64, resulting in a coinsurance obligation of $9.33.

For the CPAP full face mask (A7030), the allowed amount of the claim is $111.94, resulting in a coinsurance obligation of $22.39.

For the airway headgear (A7035), the allowed amount of the claim is $19.61, resulting in a coinsurance obligation of $3.92.

For the airway filter (A7038), the allowed amount of the claim is $5.78, resulting in a coinsurance obligation of $1.16.

Your total coinsurance for these DME supplies is $82.56 ($10.80 + $34.96 + $9.33 + $22.39 + $3.92 + $1.16 = $82.56). A CPAP device and supplies 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 for a continuous positive airway pressure (CPAP) device (E0601) and supplies (E0562, A4604, A7030, A7035, A7038) provided on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telehealth visit with a specialist (99442) provided on March 11, 2021.

You asked the Plan to waive the copayment for a telehealth visit with a specialist. You say that you do not agree with being billed a copayment for a telehealth visit during Covid-19. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $40 copayment for physician/practitioner services, including doctor's office visits and telehealth visits with a specialist.

You have been asked to pay a $40 copayment for a telehealth visit with a specialist. The EOC confirms $40 is the required copayment for this service. The EOC also confirms that you pay a $40 copayment for each office visit or telehealth visit to providers other than your primary care provider (PCP). A telehealth visit with a specialist falls 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 copayment for a telehealth visit with a specialist (99442) provided on March 11, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the nerve block and neurobehavioral status exam provided on November 23, 2020.

You asked the Plan to pay for the neurobehavioral status exam (96116). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the medical records do not include the time spent in neurobehavioral status therefore the billed service 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. 

In this case, the CPT Code Manual definition of code 96116 is Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; first hour. 

We find that CPT code 96116 is not supported in the medical record. Specifically, this is a time-based procedure. There is no record of time spent on this exam. Based on this information, we decided that Medicare rules for coverage of the neurobehavioral status exam (96116) have not been met. Therefore, we decided that the Plan does not have to pay for the nerve block and neurobehavioral status exam provided on November 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the fine needle aspiration biopsy, including ultrasound guidance; first lesion (10005) provided on January 25, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $370 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay a $370 copayment for the outpatient surgery provided. 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 fine needle aspiration biopsy, including ultrasound guidance; first lesion (10005) provided on January 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on October 29, 2020.

You asked the Plan to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425). The Plan denied your request. The Plan says prior authorization is required for non-emergency transport. Additionally, non-emergent, non-urgent services with out-of-network providers require prior authorization.

The Plan contract says that prior authorization is required for non-emergency transport.

We looked at the file and the Plan's rules. The file shows that prior authorization was not obtained for the ambulance transport. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a compounded drug (J7999) provided on November 6, 2020.

You asked the Plan to waive the coinsurance for a compounded drug. You say that you had this procedure done in the past and paid a lower cost share. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay a 20% coinsurance for a compounded drug. The allowed amount of the claim is $285, resulting in a coinsurance obligation of $57. The EOC confirms 20% is the required coinsurance for this service. A compounded drug falls within the Medicare Part B prescription drugs 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 compounded drug (J7999) provided on November 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on January 08, 2021 and January 11, 2021.

You asked the Plan to pay for this service. You say that this claim should be paid because Medicare rules state that the codes used are valid for Covid 19 testing. The Plan denied your request. The Plan says it was unable to confirm that you are CLIA certified by Medicare and therefore you are not eligible for Medicare payment.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. Providers must also be eligible to accept Medicare Payment.

In this case, Maximus has confirmed that the providers CLIA number does not show active on the government website. We were unable to confirm the provider was an eligible provide at the time of service. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on January 08, 2021 and January 11, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit billed with 99285 and provided on
December 18, 2020.

You asked the Plan to pay for an emergency room. You say that this was billed correctly. The Plan denied your
request. The Plan says the records support 99284 instead of 99285.

The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect
the services provided.

In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the
evaluation and management of a patient which requires three components (taking into account the urgency of
the clinical condition or the patient's mental status):

1. a comprehensive history;
2. a comprehensive examination; and
3. medical decision making of high complexity.

In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate
significant threat to life or physiologic function.

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 an emergency room Our reviewer says that
the billing of 99285 is not supported in the records. Our reviewer found the documentation only substantiates
moderate medical decision making.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an emergency room have not been met. Therefore, we decided that the Plan
does not have to pay for an emergency room visit billed with 99285 and provided on December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, topical
application of fluoride varnish, and prophylaxis provided on March 8, 2021.

You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, topical application of fluoride
varnish, and prophylaxis. You say that the agent you worked with never advised that certain dentists do not
accept your plan. The Plan denied your request. The Plan says the treating provider has been excluded from
Medicare participation.

The Plan must follow Medicare rules. The rules say that section 1128 of the Social Security Act provides the
authority to Medicare to exclude various health care providers from receiving payment under Medicare.

Though the Plan offers a dental benefit in excess of Medicare coverage, the treating provider has been excluded
from Medicare participation. Therefore, we decided that the Plan does not have to pay for the periodic oral
evaluation, bitewing x-rays, topical application of fluoride varnish, and prophylaxis provided on March 8,
2021.