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

 
We decided that the Plan does not have to pay for ground mileage, per statute mile (A0425) and ambulance 
service, basic life support, non-emergency transport, (bls) (A0428) provided on January 28, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says ambulance services used for the transportation of a hospital inpatient to another facility 
for diagnostic tests or special treatment is considered part of the inpatient admission, and not separately 
payable. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. The patient was in an inpatient 
hospital status. According to Medicare rules, ambulance services used for the transportation of a hospital 
inpatient to another facility for diagnostic tests or special treatment is considered part of the inpatient 
admission, and not separately payable. 
 
The provider billed codes A0428 and A0425 with modifier HN for date of service January 28, 2020 under 
claim type P (professional). The referenced claim which was bill type 0111 (Hospital Inpatient Part A) admit 
date December 29, 2019 and discharge date January 20, 2020. Therefore, A0428 and A0425 denied correctly 
because on this date of service, January 28, 2020, the patient was inpatient hospital status. A corrected claim 
can be submitted to the claims address on the back of the member's ID card with a valid procedure code for 
claim reconsideration. The member is not responsible for payment. Therefore, we decided that the Plan does 
not have to pay for ground mileage, per statute mile (A0425) and ambulance service, basic life support, non-
emergency transport, (bls) (A0428) provided on January 28, 2020.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the testing provided to the enrollee on November 
13, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that clinical information from the requesting specialty provider was not provided. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the Plan is not clear on rationale for denial. The patient with indication for test based on 
diagnosis and need for chemotherapy. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
the testing provided to the enrollee on November 13, 2019.  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus vaccine provided on January 21, 2020. 
 
You asked the Plan to pay for the tetanus vaccine. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the tetanus vaccine is not covered under your 
Medicare Part B benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the tetanus 
vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus vaccine provided on January 
21, 2020.  
 
Benefits for the tetanus vaccine may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of torus mandibularis provided on February 10, 
2020. 
 
You asked the Plan to pay for removal of torus mandibularis. You say that you had a bony ridge in your mouth 
causing your tongue to protrude, you couldn't speak and were at risk of developing problems with your salivary 
glands. You say that you needed the surgery to remove the growths and have a functional mouth. The Plan 
denied your request. The Plan says the service is not a covered benefit. 
 
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. Therefore, we decided that the Plan does not have to pay for removal 
of torus mandibularis provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies (NCS) and electromyography 
(EMG) testing provided on August 14, 2019 billed with codes 95909 and 95886. 
 
You asked the Plan to pay for the NCS/EMG studies as billed. You say that these services were billed correctly 
and were medically necessary. The Plan denied your request. The Plan says the documentation does not 
support that the services described by these codes were performed. 
 
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 95909 is Nerve conduction studies; 5-6 studies. The CPT 
Code Manual definition of 95886 is Needle electromyography, each extremity, with related paraspinal areas, 
when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more 
muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to 
code for primary procedure). 
 
We asked our coding 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 NCS/EMG studies as billed. Our 
reviewer says that the documentation does not support the billed codes. Our reviewer found the CPT code 
95909 is not supported by the records. Pedicle screw or direct root stimulations are not baseline nerve 
conduction studies which would include measurements of amplitude, latency, and conduction velocity, 
therefore, the requested procedure code is not substantiated in the operative narrative and 95909 cannot be 
verified. The codes 95886 are also not supported. The medical records provided does not include 
documentation of a complete needle electromyography done with nerve conduction. Pedicle screw stimulations 
are not baseline nerve conduction studies. There is a more appropriate billable CPT code for a complete EMG 
without nerve conduction studies. 
 
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 NCS/EMG studies as billed have not been met. Therefore, we decided that 
the Plan does not have to pay for the nerve conduction studies (NCS) and electromyography (EMG) testing 
provided on August 14, 2019 billed with codes 95909 and 95886.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99203) and vascular procedures (37225, 
37229, 37233, 37252, 37253, 36200, 36140, 36245, 36246, 36247, 75710) provided on August 1, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for an office visit and vascular procedures. You say that these services were 
medically necessary. The Plan denied your request. The Plan says these services were not authorized. 
 
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 an office visit (99203) and vascular procedures 
(37225, 37229, 37233, 37252, 37253, 36200, 36140, 36245, 36246, 36247, 75710) provided on August 1, 2019 
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 28, 
2020 to January 29, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was correctly rendered as 
inpatient care. The Plan denied your request. The Plan says the enrollee had surgery and spent one night in the 
hospital which could have been appropriately provided in the outpatient setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee is a 71 year old male with a past medical history of hypertension and 
stage III chronic kidney disease who was admitted to an acute hospital on 01/28/2020 for simultaneous bilateral 
knee replacements for advanced symptomatic bilateral knee osteoarthritis. He did well with surgery and was up 
and ambulatory the next day and discharged to home on 01/29/2020. 
 
 
 
The record does not show that at the time of inpatient admission the admitting physician reasonably expected 
that the patient's necessary hospital care (including earlier ED and/or observation care) would span two 
midnights. The pre-operative history and physical documents stable hypertension and chronic kidney disease 
and indicated that the patient was a "low risk candidate for a moderate risk surgery." A planned outpatient 
surgery with an overnight observation appears to have been appropriate with the option to transition the patient 
to inpatient status if his condition warranted further hospital level care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from January 28, 2020 to January 29, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the charges for the outpatient dialysis treatment provided from 
January 6, 2020 to April 29, 2020. 
 
You asked the Plan to waive the charges for the dialysis treatments. You say that you would like these charges 
to be waived as you are not able to afford this with your income. The Plan denied your request. The Plan says 
these treatments were correctly assessed to charge you 20% of the Medicare approved cost. This cannot be 
waived as it is clearly described in your contract. 
 
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 20% 
coinsurance for outpatient dialysis treatments.  
 
You have been asked to pay 20% coinsurance for the dialysis treatments. 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 charges for the outpatient dialysis treatment provided from January 6, 2020 to April 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contacts rendered to you on March 23, 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 you exhausted the benefit limit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to one pair of contact lenses every two years. 
 
We looked at the file and the Plan's rules. The file shows that you received contact lenses on April 2, 2019 for 
which the Plan approved and paid. You are not eligible for coverage of another pair of contact lenses until two 
years have passed from this date. Therefore, we decided that the Plan does not have to pay for the contacts 
rendered to you on March 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection and copayment for specialist 
services provided by a participating provider on March 5, 2020. 
 
You asked the Plan to waive the coinsurance and copayment for an injection and specialist services. You say 
that you do not agree with the cost share assessed. The Plan denied your request. The Plan says the correct 
coinsurance and copayment have 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 Medicare Part B prescription drugs and a $35 copayment for physician/practitioner 
services/specialist.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection and a $35 copayment 
for specialist services. The total allowed amount is $2,250. The total amount you are being asked to pay for an 
injection is $450 ($2,250 x 20% = $450). The total amount you are being asked to pay is $485 ($450 + $35 = 
$485). An injection falls within the Medicare Part B prescription drugs benefit category and specialist services 
falls within the physician/practitioner services/specialist 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 and copayment for an injection and specialist services provided by a participating provider on 
March 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 5, 2020. 
 
You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there 
was a more effective therapy to treat the enrollee's advanced cancer. The Plan denied your request. The Plan 
says service provider should use CPT code 81479. 
 
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 looked at the file and the rules. The claim provided does not show that the Medicare coding and billing 
guidance has been followed. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on 
April 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special pump services rendered on March 3, 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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are 
statutorily excluded.  
 
The provider submitted a claim for procedure code 99190 (special pump services). This code has a status 
indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. 
 Therefore, we decided that the Plan does not have to pay for the special pump services rendered on March 3, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided by a participating 
provider on March 19, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that you are on a fixed income and you 
cannot afford this. 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $175 copayment for outpatient diagnostic tests/advanced radiology service.  
 
The enrollee has been asked to pay a $175 copayment for an MRI. The correct copayment has been applied to 
the service that was provided. An MRI falls within the outpatient diagnostic tests/advanced radiology service 
benefit category. 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 an MRI provided by a 
participating provider on March 19, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray and CT scan provided on January 26, 2020. 
 
You asked the Plan to pay for the chest x-ray and CT scan. You say that the enrollee only had hospice until 
January 22, 2020. You say that the claim should be reprocessed for payment at the contracted rate. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 22, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray and 
CT scan provided on January 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for care planning (99483) provided on February 3, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for OON care planning. You say that the provider is not responsible for 
authorization. The Plan denied your request. The Plan says these services were not authorized. 
 
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 care planning (99483) provided on February 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 acute inpatient rehabilitation facility (IRF) 
services provided February 19, 2020 to February 26, 2020. 
 
You asked the Plan to waive the copayment for the IRF services. You say that the copayment should be 
waived. The Plan denied your request. The Plan says the correct copayment 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 $325 
per day copayment for days 1-6 for Inpatient Care.  
 
You have been asked to pay a $1,950 copayment for 6 days of IRF services. The IRF services falls within the 
Inpatient Care 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 acute inpatient 
rehabilitation facility (IRF) services provided February 19, 2020 to February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urinary incontinence assessment (1090F) 
BCG live intravesical 1mg (J9030) bladder instillation of anticarcinogenic agent (51720) interferon injection 
alfa-2b, recombinant, (J9214) provided Mary 13, 2020. 
 
You asked the Plan to waive the copayment for the urology and injection services. You say that you do not 
understand why you have to pay more than $40 copay for the visit. Even with an injection you do not 
understand why everything isn't covered? The Plan denied your request. The Plan says a Part B injection was 
rendered on this date of service therefore this claim has been processed 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 20% of 
the total cost for Medicare covered Part B prescription drugs, including chemotherapy drugs. for Medicare Part 
B prescription drugs.  
 
You have been asked to pay $388.29 for the injection services. The injection services fall within the Medicare 
Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for urinary 
incontinence assessment (1090F) BCG live intravesical 1mg (J9030) bladder instillation of anticarcinogenic 
agent (51720) interferon injection alfa-2b, recombinant, (J9214) provided Mary 13, 2020.