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

 
We decided that the Plan does not have to pay for emergency department visit for the evaluation and 
management (99285) provided December 18, 2019. 
 
You asked the Plan to pay for emergency department visit. You say that you would like to appeal the decision 
based on the fact that the enrollee was seen at two different times. The Plan denied your request. The Plan says 
the submitted documentation supports 1 unit of 99285, which was previously approved/paid. There is no 
documentation supporting additional services. 
 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. The facility or hospital must furnish all necessary 
covered services to the beneficiary either directly or under arrangements made with outside providers.  
 
You provided physician services to the enrollee while in the emergency room in a facility. Payment for this 
service would have been included under the facility claim for the emergency services. Payment to you for this 
service is the responsibility of the facility or hospital. Therefore, the plan is not required to pay you separately 
for this claim. Therefore, we decided that the Plan does not have to pay for emergency department visit for the 
evaluation and management (99285) provided December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on January 21, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physician services provided on January 21, 2020 
by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare pays for ambulance services that meet certain origin and destination requirements. In order to meet this requirement, the ambulance supplier must transport the patient for whom the emergency call was placed. If an ambulance responds to a call but does not transport the person for whom the call was placed, Medicare does not pay for the service. You can find this rule at 42 CFR Section 410.40(f) and in the Medicare Benefit Policy Manual, Chapter 10, Section 10.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation, extraction, first 
15 minutes of deep sedation/general anesthesia, and each subsequent 15 minute increment of deep 
sedation/general anesthesia provided on May 14, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, extraction, and deep 
sedation/general anesthesia services. You say that these services were provided as an emergency treatment due 
to the constant pain you have experienced from previous treatments. You also say that the previous provider 
has caused a lot of damage, and you would like the money paid to them by the Plan refunded. The Plan denied 
your request. The Plan says your annual maximum benefit 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, the Plan offers a $1,000 annual dental 
benefit maximum. 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 
maximum benefit on January 2, 2020 and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the problem focused limited oral evaluation, extraction, first 15 
minutes of deep sedation/general anesthesia, and each subsequent 15 minute increment of deep 
sedation/general anesthesia provided on May 14, 2020.  
 
Your complaint about being misdiagnosed and the poor treatment rendered by the previous provider is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management service provided on 
December 12, 2019. 
 
You asked the Plan to pay for hospital discharge day management. You say that you are appealing with 
records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
the documentation does not support a hospital discharge day management service of more than 30 minutes in 
duration. 
 
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 99239 is hospital discharge day management, more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation does not 
show that the hospital discharge day management was more than 30 minutes in duration. Based on this 
information, we decided that Medicare rules for coverage of hospital discharge day management have not been 
met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management service 
provided on December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 85060 provided on February 24, 2020. 
 
You asked the Plan to pay for CPT code 85060. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 code 85060 is not supported in the medical record. Specifically, CPT 85060 may not be paid 
if furnished to hospital outpatients or non-hospital patients. Based on this information, we decided that 
Medicare rules for coverage of CPT code 85060 have not been met. Therefore, we decided that the Plan does 
not have to pay for CPT code 85060 provided on February 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the total electric hospital bed and rails purchased 
on April 15, 2020. 
 
You asked the Plan to reimburse you for the total electric hospital bed and rails. You say that because of your 
medical condition an electric hospital bed became a necessity. The Plan denied your request. The Plan says you 
obtained durable medical equipment from a provider who does not participate with Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 
Medicare rules say no Medicare payment may be made to a beneficiary for items provided directly by a 
provider who is not eligible to take Medicare payment.  
 
Payment cannot be made for items purchased from this provider because this provider is not a certified medical 
provider for Medicare. Therefore, we decided that the Plan does not have to reimburse you for the total electric 
hospital bed and rails purchased on April 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (97163, 97110, 97112 and 97530) 
provided on December 31, 2019 through January 3, 2020. 
 
You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says there is a more appropriate code used for 
these services. 
 
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 coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the physical therapy services. Our reviewer says that CPT 
codes 97163, 97110, 97112 and 97530 do not meet criteria for billing or reimbursement consideration. Our 
reviewer found the record indicates that these services were provided in a home health setting. There is a more 
appropriate code for this service when provided in this setting. 
 
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 physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pay for physical therapy services (97163, 97110, 97112 and 97530) provided on 
December 31, 2019 through January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on June 10, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the chiropractic services. You say that you were not aware you needed another 
letter from the provider. You have since received authorization for further treatments. The Plan denied your 
request. The Plan says enrollees 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 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 services provided on June 10, 
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 inpatient hospital care from April 23, 2020 
through April 24. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you never left the 
emergency room and you are now being billed as if you were inpatient. The Plan denied your request. The Plan 
says the claim submitted for the dates of service was for inpatient hospital care. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows that you were admitted on April 23, 2020 and discharged on April 24, 2020. You 
were asked to pay a $325 copayment for April 23, 2020, day 1 of your inpatient hospital care. You were 
discharged on April 24, 2020 and there was no copayment charge for the day of discharge. Per your contract 
there is a $325 copayment per day required for days 1-5. 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 inpatient hospital care from April 23, 2020 through April 24.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating hospital on March 13, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you were not told that you 
would have two copayments. 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 $275 
copayment for outpatient surgery/outpatient hospital facility.  
 
You have been asked to pay a $275 copayment for an outpatient surgery. The procedure that was provided is 
considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls 
within the outpatient surgery/outpatient hospital facility 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 outpatient surgery provided by a participating hospital on March 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 8, 2019. 
 
You asked the Plan to pay for the laboratory 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 are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, 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. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physician?s intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on August 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-ray and 2 additional resin-based composites 
provided on April 1, 2020. 
 
You asked the Plan to pay for the intraoral x-ray and 2 additional resin-based composites. You say that you 
were informed you owe nothing because this was covered by insurance. You say that you did not do x-rays at 
the visit. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 have a maximum benefit of 
one resin-based composite per calendar year. The Plan paid for one resin-based composite provided on April 1, 
2020, which exhausted your benefit. The intraoral x-ray is not listed as a covered benefit. Therefore, we 
decided that the Plan does not have to pay for the intraoral x-ray and 2 additional resin-based composites 
provided on April 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on February 19, 2020. 
 
You asked the Plan to pay for drug test. You say that you are appealing based on medical necessity. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because the documentation 
submitted does not include a valid physician order, lab requisition, or medical records stating exactly which 
tests were to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan 
does not have to pay for drug testing provided on February 19, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the 
out of network (OON) provider on November 27, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the domiciliary or rest home visit (99335) rendered by the out of network (OON) provider on 
November 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lower partial denture provided on March 26, 2020. 
 
You asked the Plan to pay for the lower partial denture. You say that you never received the lower partial from 
the previous dentist. You say that the plan should pay so you can get the lower partial. The Plan denied your 
request. The Plan says the service exceeds the maximum allowed. 
 
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, you also have a maximum benefit of 
one lower partial denture every five plan years. The Plan paid for a lower partial denture billed on November 7, 
2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the lower 
partial denture provided on March 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360? molecular pathology genomic profiling 
provided to the enrollee on November 27, 2018. 
 
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 Medicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic 
profiling for cancer. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 Guardant360 molecular pathology genomic profiling provided to the enrollee on November 27, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from March 6, 2020 through March 16, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that this copayment is 
too much to pay when you have insurance. The Plan denied your request. The Plan says you were charged this 
copayment 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 $350 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $350 copayment per day for days 1-5 for the inpatient hospital services, for a 
total of $1800. 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 inpatient hospital services you received 
from March 6, 2020 through March 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an inpatient hospital stay provided by a 
participating provider on March 9, 2020 to March 12, 2020. 
 
You asked the Plan to waive the coinsurance for an inpatient hospital stay. You say that you did not receive 
special care while in the hospital. You say that you feel like this coinsurance is too high. The Plan denied your 
request. The Plan says the correct coinsurance 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 20% 
coinsurance for inpatient hospital care/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an inpatient hospital stay. The total 
allowed amount is $4,621.71. The total amount you are being asked to pay is $924.34 ($4,621.71 x 20% = 
$924.34). Since an inpatient hospital stay occurred, the correct coinsurance has been applied. An inpatient 
hospital stay falls within the inpatient hospital care/in-network. 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 an inpatient hospital stay provided by a participating provider on March 9, 2020 to 
March 12, 2020.