Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says coverage criteria was not met. 
 
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 record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier emergency and/or 
observation care) would span two midnights. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the EKG (CPT Code 93010) provided on July 10, 2020. 
 
You asked the Plan to pay for the EKG. You say that the service was necessary. The Plan denied your request. 
The Plan says this code is not a Medicare benefit for the diagnoses listed on the claim and is done for screening 
purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, the EKG, was requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the EKG 
(CPT Code 93010) provided on July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the phone evaluation and management 
service provided on April 20, 2020. 
 
You asked the Plan to waive the copayment for the phone evaluation and management service. You say that 
you should not be responsible for the copayment because you did not see the doctor on this date of service. The 
Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 visits to an in-network specialist.  
 
You have been asked to pay a $45 copayment for the phone evaluation and management service. The phone 
evaluation and management service falls within the Physician/Practitioner services, including doctor?s office 
visits benefit category. The medical record shows you consented to, and had a 5 to 10-minute telephone 
encounter on this date of service. 
 
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 phone evaluation and management service provided on 
April 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99238) provided on 
March 4, 2020. 
 
You asked the Plan to pay for the hospital discharge day management. You say that these services were 
medically necessary. The Plan denied your request. The Plan says no records were received regarding this 
specific date of service. 
 
The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must 
furnish to the intermediary or carrier sufficient information 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 these services have not been met. Specifically, there were no medical records provided in this case 
for the March 4 claim. Without the medical records, we cannot review to see if the services were 
urgent/emergent or medically necessary. Therefore, we decided that the Plan does not have to pay for the 
hospital discharge day management (99238) provided on March 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of the lower leg (73590) provided on August 13, 
2020. 
 
You asked the Plan to pay for the x-ray of the lower leg. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the services have been appended with an 
RT modifier for the right side, and the diagnosis codes reported all indicate the left side. 
 
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 73590 is not supported in the record. Specifically, the appended modifier and records 
indicate that this service was rendered on the right side. The diagnosis codes on the claim all indicate the left 
side. Based on this information, we decided that Medicare rules for coverage of the x-ray of the lower leg have 
not been met. Therefore, we decided that the Plan does not have to pay for the x-ray of the lower leg (73590) 
provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-share for the office visit and injection provided. 
 
You asked the Plan to waive the cost-share for the services. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Review of the file show that you received specialist office services 
and a Methylprednisolone 40MG injection. You are asked to pay a $25 copayment for the specialist office 
services and 15% coinsurance for the injection. Your EOC states that enrollees must pay 15% of the total cost 
for Medicare-covered Part B prescription drugs, including chemotherapy drugs and a $25 copayment for each 
specialist visit. 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 cost-share for the office visit and injection provided.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation service 
(A0427, A0425) provided on December 29, 2019. 
 
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 $75 
copayment for each one-way ambulance trip for emergency transportation.  
 
You have been asked to pay a $75 copayment for the one-way ambulance transportation service 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 ambulance transportation service (A0427, A0425) 
provided on December 29, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the eye exam provided on October 22, 2019. 
 
You asked the Plan to pay for the eye exam. You say that you did not have a routine eye exam at the visit on 
January 3, 2019. The Plan denied your request. The Plan says that you exhausted your benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide enough information to verify that the exam on January 
3, 2019, was a routine examination. There was diagnostic testing performed on the same date of service; 
therefore, the Plan should pay for the examination on October 22, 2019. Therefore, we decided that the Plan 
has to pay for the eye exam provided on October 22, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on August 18, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 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 medical services provided to you by an out-of-network provider on 
August 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6751) for teeth #18, 20, 27, 29, and 
30, and the pontics (D6242) for teeth #19 and 28. 
 
You asked the Plan to pre-approve the dental services. You say that you decided to get a bridge instead of 
implants. You say that you would have to wait for a long time for your gums to heal before you can get 
implants. You say that you have had bridges before. You also say that your dentist is well qualified to do either 
job. The Plan denied your request. The Plan says retainer crowns are not listed as covered services. The Plan 
says that pontics are not listed as covered services either. 
 
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 pre-approve 
retainer crowns (D6751) for teeth #18, 20, 27, 29, and 30, and the pontics (D6242) for teeth #19 and 28.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on May 
14, 2020. 
 
You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare denies 
coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients 
with suspected or documented cardiovascular disease. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, the cardiovascular risk assessment testing, was requested solely for screening 
purposes. Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, 
for symptomatic patients with suspected or documented cardiovascular disease. Therefore, we decided that the 
Plan does not have to pay for the cardiovascular risk assessment testing provided on May 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the right ankle. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is noted to have chronic 
ankle and foot pain with previous foot surgery. There are no records of these events. An office note from 
November of 2020 describes varus deformity of the right ankle and a ruptured Achilles tendon. It is unclear 
how this documentation supports the need for a CT scan of the ankle or foot, the need for ankle replacement 
surgery, or the appeal argument that the enrollee has bone-on-bone osteoarthritis. The CT scan is not 
reasonable or medically necessary. 
 
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 pre-approve a computed tomography (CT) scan of the right ankle.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the digital breast tomosynthesis rendered on August 20, 
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 77062 is not covered. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid 
for Medicare purposes.  
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure code 77062. This code 
has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not 
have to pay for the digital breast tomosynthesis rendered on August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit services provided to the enrollee on July 2, 2020. 
 
You asked the Plan to pay for the services. You say that you were an active and qualified Medicare provider at 
the time of service of the claim. The Plan denied your request. The Plan says no provider or supplier shall 
receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in 
the Medicare program. 
 
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 who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for office visit 
services provided to the enrollee on July 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the complete series x-ray (D0210) and the scaling 
in the presence of gingival irrigation (D4346) provided on August 21, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that the dental clerk advised that the 
services would be covered. You also say that you checked your list of benefits and x-rays and teeth cleanings 
are covered 100%. The Plan denied your request. The Plan says the complete series x-ray is not listed as a 
covered service. The Plan also says that scaling in the presence of gingival irrigation is not listed as a covered 
service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for 
the complete series x-ray (D0210) and the scaling in the presence of gingival irrigation (D4346) provided on 
August 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of the small intestine (74250) provided on July 10, 
2020. 
 
You asked the Plan to pay for the x-ray. You say that you would like reconsideration because this service was 
billed correctly. The Plan denied your request. The Plan says this claim was billed with an outpatient place of 
service code, but the member was inpatient during this date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician/practitioner/supplier furnishing 
services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 
21 irrespective of the setting where the patient actually receives the face-to-face encounter. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the x-ray have not been met. The record indicates that the member was registered inpatient on the 
billed date of service. Therefore, it is inappropriate to bill this service with an outpatient place of service code. 
Therefore, we decided that the Plan does not have to pay for the x-ray of the small intestine (74250) provided 
on July 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic ultrasound procedures of the 
head and neck (76536) injection, denosumab, 1 mg (J0897) provided June 20, 2020, to September 1, 2020. 
 
You asked the Plan to waive the copayment for the radiology and injection services. You say that you are 
appealing these bills because you cannot afford to pay them. All of these costs are just too expensive. In the 
past, other insurance companies have covered the cost of these bills. The Plan denied your request. The Plan 
says the claim was processed and the correct cost share was applied per the Evidence of Coverage. 
 
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 all other drugs covered under Medicare Part B and $50 copay for x-rays.  
 
You have been asked to pay $288.80 (238.80 + $50) for the radiology and injection services. The radiology and 
injection services falls within the Medicare Part B prescription drugs and 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 
diagnostic ultrasound procedures of the head and neck (76536) injection, denosumab, 1 mg (J0897) provided 
June 20, 2020, to September 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services rendered on July 1, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that outpatient hospital services must be submitted 
with TOB code 13x. 
 
We looked at the file and Medicare rules. The file shows that the outpatient hospital services were not billed 
with TOB code 13x. 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 outpatient hospital services 
rendered on July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PPE provided on May 26, 2020. 
 
You asked the Plan to pay for the PPE. You say that the Plan should pay a portion of the bill because this was 
your first cleaning of 2020. The Plan denied your request. The Plan says $20.00 is your liability is for the PPE. 
The Plan also says that PPE 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 the PPE 
provided on May 26, 2020.