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

 
We decided that the Plan does not have to pay for the laboratory services provided on September 10, 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 providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
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 provided on 
September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy (97026) provided on May 7, 2020. 
 
You asked the Plan to pay for infrared therapy. You say that this was medically necessary. The Plan denied 
your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that that there is sufficient evidence to conclude the 
use of infrared therapy devices and any related accessories is not reasonable and necessary. 
 
We looked at the file and Medicare rules. The infrared therapy at issue is considered not reasonable and 
necessary and is not covered. Based on this information, we decided that Medicare rules for coverage of 
infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay for infrared 
therapy (97026) provided on May 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Hyaluronan or derivative, durolane 
injections (J7318 RT, LT) and the Triamcinolone acetonide injection (J3301) provided on February 17, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says coinsurance has 
been applied correctly to 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% 
coinsurance for each Medicare-covered Part B drug.  
 
You have been asked to pay $404.27($2,021.36 allowed amount x 20% coinsurance) for the Medicare-Part B 
drugs administered. 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 the Hyaluronan or derivative, 
durolane injections (J7318 RT, LT) and the Triamcinolone acetonide injection (J3301) provided on  
February 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 18, 2020 to April 
19, 2020. 
 
You asked the Plan to pay for these services. You say that you have never been billed above a $90 copayment. 
The Plan denied your request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of 
the PC of radiology services when furnished in a different payment locality than the TC. 
 
We looked at the file and Medicare rules. The file shows that the provider submitted a claim for the laboratory 
codes with modifier -26. This modifier is not appropriate for these codes. 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 laboratory services rendered on April 18, 2020 to April 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1833) provided to the enrollee on April 7, 
2020. 
 
You asked the Plan to pay for this. You say that the claim should be paid. The Plan denied your request. The Plan 
says the documentation does not indicate services are necessary for treatment of the enrollee's condition. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the durable medical equipment have not been met. Specifically, medical records do not support a 
prior face-to-face examination with the ordering physician conducting a visit with the intent of ordering the 
DME. The submitted consultation notes do not support that a physical examination was performed in 
conjunction with the need for the orthosis. The information submitted does not confirm that Medicare coverage 
criteria have been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833) 
provided to the enrollee on April 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nerve conduction studies (95907) and needle 
electromyography (95885) provided on March 3, 2020. 
 
You asked the Plan to pay for the nerve conduction studies and needle electromyography. You say that you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the 
documentation submitted does not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95907 is nerve conduction studies; 1-2 studies. 
 
The CPT code Manual definition of CPT code 95885 is needle electromyography, each extremity, with related 
paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited 
(List separately in addition to code for primary procedure).  
 
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 nerve conduction studies and needle electromyography. 
Our reviewer says that CPT code 95907 does not meet criteria for billing or reimbursement consideration. The 
medical records provided do not include documentation to validate that a Nerve conduction studies; 1-2 studies 
was performed on March 3, 2020. Nerve stimulation that was performed by the surgeon does not meet the 
description of 95907, therefore this service cannot be verified. Our reviewer found CPT code 95885 does not 
meet criteria for billing or reimbursement consideration.  Because the medical records do not corroborate CPT 
95907 the result is the CPT definition of 95885 is not met in the documentation. 
 
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 nerve conduction studies and needle electromyography have not been met. 
Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95907) and needle 
electromyography (95885) provided on March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical stockings full length (CPT Code A4510) and 
gradient compression stocking, waist length, 40-50 mmhg (CPT Code A6541) provided on April 27, 2020. 
 
You asked the Plan to pay for the compression stockings. You say that you are requesting reimbursement of 
services rendered. The Plan denied your request. The Plan says this items are not covered under Medicare or 
the Health Plan. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A4510 and 
A6541 are noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for surgical stockings full 
length (CPT Code A4510) and gradient compression stocking, waist length, 40-50 mmhg (CPT Code A6541) 
provided on April 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 8, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were unable to find a dentist that accepted 
your insurance. You say that you were informed to pay up front then submit your claim for reimbursement. The 
Plan denied your request. The Plan says your provider submitted the claim with invalid service code D9074; 
therefore, you will not receive a reimbursement for your claim cost. 
 
The Plan must follow Medicare rules. Medicare rules say that sufficient information must be furnished to 
determine whether payment is due and the amount of payment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the dental services have not been met. Without documentation showing the actual services 
rendered or a valid code describing the services, it cannot be determined if payment is due. Therefore, we 
decided that the Plan does not have to pay for dental services provided on January 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient office visits (99204) 
debridement of wounds (11042) provided March 10, 2020 to May 19, 2020. 
 
You asked the Plan to waive the copayment for outpatient office visits. You say that this is the same doctor 
who had been treating your leg. He just started using a new medication. It was only a new medication not a 
surgical procedure and you are disputing the huge copay of $295. The Plan denied your request. The Plan says 
the initial copay applied was $295 for outpatient hospital surgery. After additional review, the plan has 
redetermined that $45 for physician specialist copayment should apply for these services. 
 
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 $45 for 
physician specialist services.  
 
You have been asked to pay $495 ($45 x 11 = $495) for outpatient office visits. The outpatient office visits fall 
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 outpatient office visits (99204) debridement of wounds (11042) 
provided March 10, 2020 to May 19, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on December 26, 2019. 
 
You asked the Plan to pay for the nurse practitioner 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 
services at issue. 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 nurse practitioner services provided on December 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided June 4, 
2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the copayment should 
be waived. The Plan denied your request. The Plan says 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 $275 
per day copayment for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $275 copayment for one day of inpatient hospital care. 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 provided June 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospitalization the enrollee 
had from April 2, 2020 through April 6, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospitalization. You say that you cannot afford 
this amount. The Plan denied your request. The Plan says the enrollee was 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $350 copayment per day for days 1-5 for inpatient hospital services.  
 
The enrollee has been asked to pay a $350 copayment per day for each day of his 4-day admission. This means 
that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing 
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the 
Plan does not have to waive the copayment for the inpatient hospitalization the enrollee had from April 2, 2020 
through April 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on November 27, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the federally qualified health center visit (G0467) and the 
office visit (99213) rendered by the out of network (OON) provider on March 11, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the federally qualified health center visit (G0467) and the office visit (99213) rendered 
by the out of network (OON) provider on March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for naturapath services that you provided on February 4, 2020. 
 
You asked the Plan to pay for the naturapath services. You say that you were unaware that authorization was 
required for this Medicare Advantage Plan. The Plan denied your request. The Plan says you are not a 
participant in the Plan?s Medicare Alternative Care network. 
 
The rules say that Medicare does not cover the services of a naturopath. However, the Plan offers a benefit that 
exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan pays for the 
services of a naturopath only services provided by a licensed naturopath obtained to diagnose and treat an 
illness or injury. 
 
We looked at the file, the Plan?s rules and Medicare rules. The file shows you are not contracted under the 
Plan's Medicare Alternative care network of providers. Therefore, we decided that the Plan does not have to 
pay for naturapath services that you provided on February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist office visit and an ultrasound 
provided on January 14, 2020. 
 
You asked the Plan to waive the copayments for a specialist office visit and an ultrasound. You say that you do 
not think you should be charged both copayments because the services occurred at the same visit. 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 $45 
copayment for each covered specialist office visit and a $45 copayment for each covered diagnostic procedure 
or test at a network doctor?s office.  
 
You have been asked to pay a $45 copayment for a specialist office visit and a $45 copayment for an 
ultrasound. Therefore, your total copayment obligation is $90. A specialist office visit falls within the 
physician/practitioner services, including doctor?s office visits, benefit category. An ultrasound falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayments for a specialist office visit and an ultrasound provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for chiropractic services you received from 
April 1, 2020 through April 16, 2020. 
 
You asked the Plan to waive the deductible for the chiropractic services. You say that you had a referral for 
chiropractic care so it is not right that your Plan didn't pay anything towards these services. The Plan denied 
your request. The Plan says you had not yet exhausted your deductible at the time of these services, so you 
were charged this amount correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible that applies to chiropractic services.   
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for 
chiropractic care. This cost sharing is a contractual obligation that had not been met at the time the out-of-
network chiropractic services was received on April 1, 2020 to April 16, 2020. Therefore, we decided that the 
Plan does not have to waive the deductible for chiropractic services you received from April 1, 2020 through 
April 16, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the myocardial perfusion imaging, 
tomographic (SPECT) (78452) and the laboratory service (80061) provided on March 17, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance 
has been applied correctly to 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% 
coinsurance for diagnostic radiology and laboratory tests.  
 
You have been asked to pay $251.12 ($1,255.58 allowed amount x 20% coinsurance) for the diagnostic 
radiology and laboratory tests 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 coinsurance for the 
myocardial perfusion imaging, tomographic (SPECT) (78452) and the laboratory service (80061) provided on 
March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing home health services provided on May 7, 
2019 to July 16, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the skilled nursing services. You say that the records provided should support the 
necessity of the services in dispute. The Plan denied your request. The Plan says this provider is not a Medicare 
certified facility and is not eligible for payment. 
 
The plan must follow Medicare rules. Medicare rules say that the Plan will generally cover your medical care 
as long as the care you receive is considered medically necessary and you receive your care from a provider 
who is eligible to provide services under Original Medicare. As a member you can receive your care from 
either a network provider or an out-of-network provider. 
 
The requested provider in this case is a non-Medicare approved/certified facility. 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 skilled nursing home health services provided on May 7, 2019 to July 16, 2019 by an out of network 
(OON) provider.