Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring 
services (95940) and the needle (A4215) provided. 
 
You asked the Plan to pay for CPT codes 95940 and A4215. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the enrollee received these services in the 
facility during an inpatient hospitalization and payment for these services would be included in the
DRG payment to the facility. The Plan states payment for these services is the responsibility of the facility. 
 
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or 
hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. In this case, the file shows that enrollee received these services 
during an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, 
we decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring 
services (95940) and the needle (A4215) provided.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the unspecified preventive service PPE provided on June 18, 2020. 
 
You asked the Plan to pay for the PPE. You say that you would like reconsideration for this service. The Plan 
denied your request. The Plan says that your plan does not provide benefits for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that the health plan must provide you with a clear and 
accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under 
your plan contract including applicable conditions and limitations and any other conditions associated with the 
use or receipt of the benefits.  
 
We looked at the file and Medicare rules. The Plan contract says that you have a $1,500 combined allowance 
for supplemental preventive and comprehensive dental services every year. The contract does not clearly 
provide a list of covered services, or specify that this service is excluded from coverage. You reasonably 
believed this service would be covered under your annual dental allowance. Based on this information, we 
decided that Medicare rules for coverage of the PPE have been met. Therefore, we decided that the Plan has to 
pay for the unspecified preventive service PPE provided on June 18, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sedation services (99152) provided on December 17, 2019. 
 
You asked the Plan to pay for sedation services. You say that this is documented in the records. The Plan 
denied your request. The Plan says this code is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older . 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the submitted medical 
records do not include documentation of sedation services with an independent observer being provided on 
December 17, 2019. Based on this information, we decided that Medicare rules for coverage of sedation 
services have not been met. Therefore, we decided that the Plan does not have to pay for sedation services 
(99152) provided on December 17, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on June 
19, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you feel you should not 
be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received ambulance services on the date of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $250 
copayment for Ambulance services.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received ambulance 
services on June 19, 2020. You have been asked to pay a $247.22 copayment for the ambulance services, 
which is less than the contracted $250 copayment amount. The ambulance services fall 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 the ambulance services 
provided on June 19, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA testing. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary due to family history. 
The Plan denied your request. The Plan says you do not meet the guidelines for coverage of the requested 
genetic testing. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 pre-approve the testing. Our reviewer says that the 
requested testing is not medically reasonable or necessary. Our physician reviewer found testing of individuals 
with no personal history of breast cancer is considered screening and is excluded by Medicare statute. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve BRCA testing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81210, 81235, and 81275 
provided on January 28, 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 were billed incorrectly. 
 
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 81210, 81235, and 81275 are not supported in the medical record. Specifically, these 
services should be billed with code 81479. In addition, the appropriate DEX Z Code identifier should be 
entered adjacent to the code in the comment/narrative field. 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 81210, 81235, and 81275 provided on January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tumor Treatment Field Therapy (E0766). 
 
You asked the Plan to pre-approve Tumor Treatment Field Therapy. You say that Tumor Treatment Field 
Therapy is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for coverage of Tumor Treatment Field Therapy. 
 
The Plan follows Medicare rules. Medicare rules say that if all of the coverage criteria above are not met, 
claims for code E0766 will be denied as not reasonable and necessary. 
 
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 pre-approve Tumor Treatment Field Therapy. Our 
reviewer says that Tumor Treatment Field Therapy is not medically necessary at this time. Our physician 
reviewer found the enrollee has newly diagnosed Glioblastoma Multiforme (GBM) that has progressed on 
treatment. He does not meet the coverage criteria because he has progression of the GBM. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tumor Treatment Field Therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Tumor Treatment Field Therapy (E0766).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for personal protective gear and ambulance cleaning billed due 
the enrollee under code A0999. 
 
You asked the Plan to pay for this code. You say that this claim should be paid. The Plan denied your request. 
The Plan says this code is not paid 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, code A0999 is not a Medicare 
payable code for reimbursement. Medicare rules for coverage of this code have not been met. Therefore, we 
decided that the Plan does not have to pay for personal protective gear and ambulance cleaning billed due the 
enrollee under code A0999.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services provided to the enrollee on March 6, 
2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim and appeal we untimely filed. 
 
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 date of service was March 6, 2019. 
The claim was not filed until March 14, 2020. The claim was denied, however not appeal with a valid waiver of 
liability until September 24, 2020. This means that more than one calendar year from the date of service had 
passed before a claim was filed and no good caused was presented for appealing well over a year later. 
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on 
March 6, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on January 22, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. 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 drug testing services provided on January 22, 2020.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for the inpatient hospital care. We decided that the plan 
does not have to waive the cost-sharing in full. 
 
You asked the Plan to waive the coinsurance for the inpatient hospital care. You say that you were told 
Medicare would cover the stay in full. The Plan says that the correct cost-sharing was 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 20% 
coinsurance up to a maximum of $1,969 for days 1-6 of inpatient hospital care. Therefore, we decided that the 
Plan does not have to waive the coinsurance entirely. The plan applied a 20% coinsurance for a total of 
$2,318.89. This exceeds the $1,969 maximum noted in the Evidence of Coverage. The plan must reduce the 
applied coinsurance to the maximum out-of-pocket amount of $1,969 as stipulated on page 5 of the 2020 
Evidence of Coverage. 
 
 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on August 3, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 physician services provided on August 3, 2020 
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the observation services provided. 
 
You asked the Plan to waive the copayment for the observation services. You say that you should not have to 
pay this copay because you had complications from your surgery. The Plan denied your request. The Plan says 
that you are responsible for the cost sharing. 
 
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 outpatient hospital observation services.  
 
You have been asked to pay a $225 copayment for the observation services. The observation services fall 
within the outpatient hospital observation 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 the observation services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diabetic supplies rendered onMay 24, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary.We looked at the file and Medicare rules. There is no valid physician order for the DME. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe diabetic supplies rendered on May 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 17, 2020. 
 
You asked the Plan to pay for the physician's 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 
physician?s 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 physician's services provided on August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 01922 provided on July 17, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 anesthesia services coded 01922 provided on 
July 17, 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 bitewing x-rays (D0274) provided on March 11, 2020. 
 
You asked the Plan to pay for the dental services. You say that your dentist office does not perform complete 
series of full mouth x-rays because of the amount of radiation that you would be subject to. You also say that 
the lesser amount for bitewing x-rays should be paid. The Plan denied your request. The Plan says bitewings 
are not listed as a covered service. 
 
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 bitewing x-rays are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bitewing x-
rays (D0274) provided on March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown, core buildup and extraction provided on 
March 3, 2020. 
 
You asked the Plan to pay more for the crown, core buildup and extraction. You say that the doctor is 
overcharging you. The Plan denied your request. The Plan says your maximum annual allowance is exhausted. 
 
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, you also had a maximum allowance of 
$1,000. The Plan paid $1,000 toward your dental benefits received on February 11, 2020, and March 3, 2020, 
which exhausted your benefit. Therefore, we decided that the Plan does not have to pay more for the crown, 
core buildup and extraction provided on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $20 copayment charged for physician services provided on 
August 19, 2019. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment was charged based on the services 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 $20 
copayment for physician visits. 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 $20 copayment charged for physician services provided on 
August 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alcohol/drug treating program services provided from 
April 13, 2020, April 19, 2020 billed with code H2036. 
 
You asked the Plan to pay for the services as billed. You say that this was approved by the Plan and should be 
paid. The Plan denied your request. The Plan says this was billed with a code not allowed 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. 
 
CPT code H2036 has a status indicator of "I" on the Physician Fee Schedule. This means that the code is 
invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage 
of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
alcohol/drug treating program services provided from April 13, 2020, April 19, 2020 billed with code H2036.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation provide don June 2, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor's office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to/from a doctor's office. 
Therefore, we decided that the Plan does not have to pay for the ambulance transportation provide don June 2, 
2020.