Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays and comprehensive 
oral evaluation provided by an OON provider. 
 
You asked the Plan to pay for the complete series of intraoral x-rays and comprehensive oral evaluation. You 
say that you were not aware that this facility was not in-network. You also say that the office took your 
insurance card, and told you that you were covered for these services. The Plan denied your request. The Plan 
says these services were rendered by a non-contracted provider. The Plan also says that you are required to 
receive services from a contracted dentist. 
 
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 requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
complete series of intraoral x-rays and comprehensive oral evaluation provided by an OON 
provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care. 
 
You asked the Plan to pay for initial observation care 99220. You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says these services may be reported only once per day by the same 
physician or physicians of the same specialty from the same group practice. 
 
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, we have confirmed that code initial 
observation care 99220 has a bundled relationship with code 99221 and cannot be paid as billed. This code 
cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for initial observation care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PCR amplification Reflex molecular UTI tests (87482, 
87799, 87150, 87798) performed July 20, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that please review and reprocess the claim 
following the CMS guidance. The Plan denied your request. The Plan says experimental or investigational 
services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. 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 PCR amplification Reflex molecular UTI tests (87482, 87799, 87150, 87798) performed July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive medicine counseling and/or risk factor 
reduction intervention(s) services provided. 
 
You asked the Plan to pay for the preventive medicine counseling and/or risk factor reduction intervention(s) 
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. 
 
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 99401 is preventive medicine counseling and/or risk 
factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes.  
 
We find that CPT code 99401 is not supported in the medical record. Specifically, this code has a status code of 
?N?. A status code of N means that these services are non-covered. Based on this information, we decided that 
Medicare rules for coverage of the preventive medicine counseling and/or risk factor reduction intervention(s) 
services have not been met. Therefore, we decided that the Plan does not have to pay for the preventive 
medicine counseling and/or risk factor reduction intervention(s) services provided.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (19301) provided. 
 
You asked the Plan to pay for surgical services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider is not eligible for payment as an assistant surgeon. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical services (19301) provided.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the fingers (73140) provided. 
 
You asked the Plan to pay for the x-ray of the fingers. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim did not include a required modifier. 
 
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 73140 is not supported in the medical record. Specifically, a required anatomical 
modifier to denote which finger the x-ray was performed on was not included. Based on this information, we 
decided that Medicare rules for coverage of the x-ray of the fingers have not been met. Therefore, we decided 
that the Plan does not have to pay for an x-ray of the fingers (73140) provided.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on June 19, 2020.
You asked the Plan to pay for the ambulance service and ground mileage. The Plan denied your request. The Plan says services received while a hospice flag is elected are covered by Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ambulance service and ground mileage provided on June 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core buildup, including any pins 
when required (D2950) provided. 
 
You asked the Plan to pay for the crown and core buildup. You say that you contacted the Plan and were told 
that root canals and crowns were each covered at $500, and you would be responsible for all costs over that. 
You also say that you did not receive any information regarding what is and is not covered under your 2020 
benefits. The Plan denied your request. The Plan says these services are not covered benefits under your dental 
plan. The Plan also says that the customer service calls were reviewed, and the caller was informed that root 
canals and crowns are not covered. 
 
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 requested items or services are not 
among those covered under this benefit. The Plan also confirmed that you were sent the 2020 EOC on 
November 6, 2019 with details of what is and is not covered by the Plan. The Plan says that you signed a 
treatment plan on July 13, 2020 advising that the services were not covered, and accepting responsibility of the 
cost. Therefore, we decided that the Plan does not have to pay for the crown (D2740) and core buildup, 
including any pins when required (D2950) provided.  
 
Your complaint about being misinformed by a Plan representative 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81201, 81209, 81162, 81242, 81272, 
81292, 81403, 81404, 81405, 81406, 81407, 81408, 81295, 81298, 81317, 81321) provided. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary ad initiated 
through telemedicine. The Plan denied your request. The Plan says this was billed with an incorrect Place of 
Service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that the use of POS codes from the National POS code set, currently maintained by CMS, is 
required. 
 
We find that the billing of the services at issue is not supported in the medical record. Specifically, these 
services were billed with POS code 81 for an independent laboratory. However, the record shows that the 
specimens were not collected in an independent laboratory, but through a mail-in system initiated through 
telehealth. Based on this information, we decided that Medicare rules for coverage of laboratory services have 
not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81201, 81209, 
81162, 81242, 81272, 81292, 81403, 81404, 81405, 81406, 81407, 81408, 81295, 81298, 81317, 81321) 
provided.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided to the enrollee. 
 
You asked the Plan to pay for the services. You say that this should be reconsidered. The Plan denied your 
request. The Plan says the provider has not submitted any documentation to support the implementation of an 
extension to the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until May, 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 air ambulance services provided to the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a vitrectomy (67036) provided on February 12, 2020.
You asked the Plan to pay for a vitrectomy. You say that this is documented as being performed on this date of
service. The Plan denied your request. The Plan says this is not supported in the records.
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 67036 is vitrectomy, mechanical, pars plana approach.
We find that CPT code 67036 is not supported in the medical record. Specifically, the procedure note for the
vitrectomy is not included in the submitted medical records. Based on this information, we decided that
Medicare rules for coverage of a vitrectomy have not been met. Therefore, we decided that the Plan does not
have to pay for a vitrectomy (67036) provided on February 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place. The Plan denied 
your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on May 7, 2020. 
 
You asked the Plan to waive the copayment for office visit. You say that you did not have an appointment and 
therefore should not responsible for a copay. The Plan denied your request. The Plan says the cost share 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 $35 
copay for Physician/Practitioner services, including doctor's office visits.  
 
You have been asked to pay a $35 copay for an office visit. This service 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 office visit provided on May 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on April 24, 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 procedure code 44140 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 44140 is colectomy, partial; with anastomosis. We find that CPT code 44140 is not supported in the medical record. Specifically, there is no documentation of a partial colectomy with anastomosis. 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 surgical services rendered on April 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided April 22, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim included an incorrect place of service. 
 
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 G0483 is not supported in the medical record. Specifically, the claim form indicates a 
Place of Service as a laboratory, while the records provided indicate that the lab draw was taken at an 
outpatient office. Based on this information, we decided that Medicare rules for coverage of the lab services 
have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided 
April 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises provided by a chiropractor on May 29, 
2020. 
 
You asked the Plan to pay for this service. You say that the Plan should pay for these services. The Plan denied 
your request. The Plan says the Plan and Medicare only cover manual manipulation of the spine and those 
services were covered. Services such as therapeutic exercises are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for therapeutic exercises provided by a chiropractor on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says the providers office confirmed you did not have a referral or prior 
authorization for this treatment. 
 
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 Plan contract specifically states chiropractic care requires a 
both a referral and prior authorization. The Plan did not pre-approve these services and you did not have a 
referral. Therefore, we decided that the Plan does not have to pay for the medical services provided by an 
out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the biopsy of the esophagus, stomach, and/or upper small bowel (43239) provided on July 1, 2020.
You asked the Plan to waive the copayment for the biopsy of the esophagus, stomach, and/or upper small bowel. You say that you never had to pay a copayment for the same procedure received in the past. The Plan denied your request. The Plan says the copayment applied correctly in this case.
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 ambulatory surgery visit. You have been asked to pay a $200 copayment for the biopsy of the esophagus, stomach, and/or upper small bowel. The service provided falls within the ambulatory surgery visit 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 biopsy of the esophagus, stomach, and/or upper small bowel (43239) provided on July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on March 4, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that your insurance did not cover your first visit to the dentist, which is the examination and x-rays. The 
Plan denied your request. The Plan says these services exceed the frequency limitation in your benefit plan. 
 
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, comprehensive oral evaluation 
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan 
years. The record shows that you received a comprehensive oral evaluation (D0150) and a complete series of 
intraoral x-rays (D0210) on February 10, 2020, and your comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not 
have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) 
provided on March 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression glove provided to the enrollee on April 20, 
2020. 
 
You asked the Plan to pay for the compression glove. You say that this should be paid. The Plan denied your 
request. The Plan says that this is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare may cover items that meet the definition of 
DME, surgical dressings, or braces. 
 
In this case, the compression glove does not fall into any of these benefit categories. It is a non-reusable supply 
which is not being used as a dressing over a qualifying wound and is not rigid or semi-rigid. Although this item 
may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage for this.  Therefore, we 
decided that the Plan does not have to pay for the compression glove provided to the enrollee on April 20, 
2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management provided. 
 
You asked the Plan to pay for the hospital discharge day management. The Plan denied your request. The Plan 
says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated 
to the enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge day management provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization inpatient care provided. 
 
You asked the Plan to pay for the post-stabilization inpatient care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the enrollee was stable for transfer to an in-network 
hospital. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post-stabilization inpatient care. Our 
reviewer says that these services were not medically necessary. Our physician reviewer found the enrollee was 
hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility. There was 
no documentation necessitating post stabilization care at the out-of-network hospital. 
 
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 post-stabilization inpatient care have not been met. Therefore, we decided 
that the Plan does not have to pay for post-stabilization inpatient care provided.