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

 
We decided that the Plan does not have to pay for drug testing provided to the enrollee on February 25, 2020 
and billed under code G0483. 
 
You asked the Plan to pay for this claim as billed. You say that this testing should be covered by the Plan. The 
Plan denied your request. The Plan says the records provided do not support the services billed. The Plan notes 
the more appropriate code to bill would have been G0482. 
 
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 records provided do not support 
the billing of G0483. The Plan suggests a corrected claim and a more appropriate code. Based on this 
information, Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan 
does not have to pay for drug testing provided to the enrollee on February 25, 2020 and billed under code 
G0483.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction provided on February 26, 2020. 
 
You asked the Plan to pay for the services provided. You say that you did not know you were seeing an eye 
specialist. The Plan denied your request. The Plan says eye refraction is not covered unless rendered by a 
routine vision provider. 
 
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.  
 
We looked at the file and the Plan's rules. The documentation shows that you received eye refraction services 
during a Medicare-covered diagnostic vision appointment. Eye refraction services are only covered during an 
annual routine exam, and when provided by a routine vision care provider. Based on this information, we 
decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the eye refraction provided on February 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the second CT provided on March 17, 2020. 
 
You asked the Plan to pay for the second CT. You say that the Plan should pay for the second CT. The Plan 
denied your request. The Plan says the wrong modifier was submitted on the claim. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -76 modifier if the 
service billed with the modifier indicates a repeat procedure by the same physician.   
 
The medical records provided do not show that the service billed with the -76 modifier was a repeat procedure 
by the same physician. Specifically, the record shows the second procedure was by another physician. Based on 
this information, we decided that Medicare rules for coverage of services billed with a -76 modifier have not 
been met. Therefore, we decided that the Plan does not have to pay for the second CT provided on March 17, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on  
April 2, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $40 
copayment for visits to specialists.  
 
You have been asked to pay a $40 copayment for the telehealth specialist visit 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 copayment for the office visit (99213) provided on April 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on March 16, 2020 to May 16, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you do not agree 
with this coinsurance. 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 durable medical equipment/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $103.76. The total amount you are being asked to pay is $20.76 ($103.76 x 20% = 
$20.76). Durable medical equipment falls within the durable medical equipment/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 durable medical equipment provided by a participating 
provider on March 16, 2020 to May 16, 2020.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided on January 22, 2020. 
 
You asked the Plan to pay for the home health services. You say that a previous claim was paid without being 
submitted on a UB-04 form. The Plan denied your request. The Plan says that home health providers must 
submit claims on a UB-04 claim form. 
 
The Plan must follow Medicare rules. Medicare rules say that the minority of providers that are eligible for an 
exception to electronic claim submission use the paper form. 
 
We looked at the file and Medicare rules. The documentation does not show that the provider at issue is 
eligible for an exception that allows for the use of the paper form UB-04. Since the provider is not eligible for 
the exception, a UB-04 claim form is not necessary. Based on this information, we decided that Medicare rules 
for coverage of the home health services have been met. Therefore, we decided that the Plan has to pay for the 
home health services provided on January 22, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered on April 13, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the 
same specialty must bill and be paid as though they were a single physician. 
 
We looked at the file and Medicare rules. The file shows that procedure codes 99291 and 99292 were billed. 
These codes must be billed on the same claim. 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 
critical care services rendered on April 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on March 8, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that your husband passed away on 
April 6, 2020. 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 $200 
copayment for ambulance services.  
 
You have been asked to pay a $200 copayment for an ambulance trip. The correct copayment has been applied 
to the services provided. An ambulance trip falls within the ambulance services benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an ambulance trip provided by a participating provider on March 8, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation services provided to the enrollee 
on April 27, 2019. 
 
You asked the Plan to pay for the services. You say that this was billed correctly. The Plan denied your request. 
The Plan says this was billed with an invalid secondary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that HCPCS codes A0425 and A0427 are not supported in the medical record. Specifically, these 
codes were billed with an improper secondary diagnosis code. 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 ambulance transportation services provided to the enrollee on April 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction provided on February 25, 2020. 
 
You asked the Plan to pay for the extraction. You say that you were referred by your general dentist. You say 
that you were informed it would be covered and you wouldn't have to pay anything out-of-pocket. The Plan 
denied your request. The Plan says payment cannot be issued for services performed by a provider who has 
opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the extraction provided on February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the immediate upper, immediate lower denture and 
extractions provided on January 27, 2020. 
 
You asked the Plan to pay more for the immediate upper, immediate lower denture and extractions. You say 
that you are being charged when you were assured there would be no additional cost. You say that you should 
have no additional financial responsibility. 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 an annual maximum of 
$1,000. The Plan paid $1,000 toward the dental services you received on January 27, 2020. The remaining 
charges are your responsibility. Therefore, we decided that the Plan does not have to pay more for the 
immediate upper, immediate lower denture and extractions provided on January 27, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided to the enrollee on March 5, 
202. 
 
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 the Type of Bill code is incorrect. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the denied codes are not supported in the medical record. Specifically, the Type of Bill code is 
incorrect. 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 skilled nursing services provided to the 
enrollee on March 5, 202.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2752) for tooth #11.
You asked the Plan to pre-approve the crown. You say that you need this crown. The Plan denied your request. The Plan says the crown is denied due to a clinically unacceptable root canal fill.
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. The Plan covers the crown when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the crown. Our reviewer says that the service is not medically necessary. Our physician reviewer found due to the inadequate root canal filling in tooth #11 and possible infection, the prognosis is poor for success of a crown placement. Our reviewer also found that the inadequate root canal treatment should be addressed prior to a crown placement. The criteria for coverage for the crown for tooth #11 have not been met at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2752) for tooth #11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110), comprehensive oral evaluation 
(D0150) and intraoral x-ray (D0210) provided by an out-of-network provider on February 18, 2020. 
 
You asked the Plan to pay for the prophylaxis (D1110), comprehensive oral evaluation (D0150) and intraoral 
x-ray (D0210). You say that you went to the website for an in-network dentist and was given the nearest dental 
office. The Plan denied your request. The Plan says out-of-network dental services are not covered benefits. 
 
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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
prophylaxis (D1110), comprehensive oral evaluation (D0150) and intraoral x-ray (D0210) provided by an out-
of-network provider on February 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from January 
1, 2020 at 11:34am through January 2, 2020. 
 
You asked the Plan to pay for post-stabilization care. You say that the claim should be paid. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 post-stabilization care. Our physician 
reviewer found the patient required close monitoring, BiPAP, and follow-up troponin testing on December 31, 
2019 to the morning the next day, and was not stable for transfer until January 1, 2020. Based on the clinical 
records, the patient appeared to be stable for transfer on 11:34 am on January 1, 2020. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan 
does not have to pay for post-stabilization care provided to the enrollee from January 1, 2020 at 11:34am 
through January 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on February 10, 2020.
You asked the Plan to waive the copayment for an MRI. You say that you were not informed of the charges at the time of the service. 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 $225 copayment for all other diagnostic and nuclear medicine radiological services. You have been asked to pay a $225 copayment for an MRI. An MRI 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 copayment for an MRI provided on February 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided a participating provider on May 21, 2020.
You asked the Plan to waive the copayment for an x-ray. You say that this should be covered because you had surgery. 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 $15 copayment for outpatient diagnostic tests/x-rays/tier 2. You have been asked to pay a $15 copayment for an x-ray. An x-ray falls within the outpatient diagnostic tests/x-rays/tier 2 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 x-ray provided by a participating provider on May 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on March 11, 2020. 
 
You asked the Plan to pay for these services. You say that you didn't know the testing would be non-covered. 
The Plan denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the submitted records show that you 
underwent semen analysis. There is no documentation to support that the testing was medically necessary. The 
services were not reasonable or medically necessary to diagnose or treat a medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. 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 March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remaining extraction provided on March 24, 2020. 
 
You asked the Plan to pay for the remaining extraction. You say that you had to have the teeth worked on. You 
say that the denial of $115 has put a financial hardship on you. The Plan denied your request. The Plan says 
your dental allowance for 2020 has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have an annual allowance of 
$800. The Plan has paid $800 toward your covered dental services provided on March 9, 2020 and March 24, 
2020, which exhausted your benefit. You are responsible for the remaining amount. Therefore, we decided that 
the Plan does not have to pay for the remaining extraction provided on March 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 31, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not include a physician order, lab requisition, or medical records stating exactly which tests were to be 
performed and some of the tests billed do not match the specimen type for testing. 
 
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 laboratory services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on January 31, 2020.