Persius/hicric huggingface dataset:
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 
7, 2020 through January 9, 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 was stable for transfer to in-network facility and no documentation noted that patient 
was too unstable for transfer. The patient did not appear to meet criteria, based on documentation, that they 
were too unstable to transfer. Therefore post-stabilization care is denied. 
 
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 7, 2020 through January 
9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power lift recliner purchased on February 4, 2020 from a 
non-Medicare certified retailer. 
 
You asked the Plan to pay for the power lift recliner. You say that nobody mentioned that you needed to 
purchase the equipment in-network. The Plan denied your request. The Plan says a provider or supplier must be 
enrolled in the Medicare program. 
 
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. 
 
Review of the file show that you purchased the power lift recliner on February 4, 2020 from a non-Medicare 
certified retailer. Medicare guidance says to receive payment for covered Medicare items or services from 
either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned 
claim), a provider or supplier must be enrolled in the Medicare program. 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 the power lift recliner purchased on February 4, 2020 from a non-Medicare certified 
retailer.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI (72197) provided on May 1, 2020. 
 
You asked the Plan to waive the copayment for the MRI. You say that you do not want to be responsible for the 
copayment because you have to get a second MRI due to the radiologist not performing the code that was 
required. 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 the MRI on May 1, 2020. You are asked to pay a $200 copayment 
for the MRI. Your EOC states that enrollees must pay a $200 copayment per provider, per date of service for 
Complex Radiology (MRI/MRA, CT scans, nuclear cardiology studies). 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 MRI (72197) provided on May 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services you received on February 21, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider 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 services you received on February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam (92012) rendered by the out of network (OON) provider on March 13, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the eye exam (92012) rendered by the out of network (OON) provider on March 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80061, 80053, 84443) rendered by 
the out of network (OON) provider on January 17, 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 laboratory services (80061, 80053, 84443) rendered by the out of network (OON) 
provider on January 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient mental health care from March 6, 
2020 through March 9, 2020. 
 
You asked the Plan to waive the copayment for inpatient mental health care. 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 shows that you were admitted on March 6, 2020 and discharged on March 9, 2020. You 
were asked to pay a $300 copayment per day from March 6, 2020 through March 8, 2020, days 1-3 of your 
inpatient hospital care. You were discharged on March 9, 2020 and there was no copayment charge for the day 
of discharge. Per your contract there is a $300 copayment per day required for days 1-4. 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 mental health care from March 6, 2020 through March 9, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DME purchased for the enrollee on January 24, 2020 
from a non-participating provider. 
 
You asked the Plan to pay for the DME. You say that you figured you were saving the Plan and the enrollee 
money by buying this item from this provider. The Plan denied your request. The Plan says the enrollee does 
not have out-of-network benefits. 
 
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 the DME purchased for the enrollee on January 
24, 2020 from a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic spinal manipulation (98941) and mechanical 
traction therapy provided on February 13, 2020. 
 
You asked the Plan to pay for chiropractic spinal manipulation and mechanical traction. You say that this 
should be covered. The Plan denied your request. The Plan says medical records were not submitted for these 
services. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The Plan offers a supplemental chiropractic benefit 
for services designed to help relieve pain, inflammation, swelling, and /or leg and foot numbness. The rules 
also 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. 
 
No medical records were submitted to show whether the criteria for Medicare-covered chiropractic services or 
the Plan?s supplemental chiropractic benefit have been met. Without this information, these services cannot be 
covered. Therefore, we decided that the Plan does not have to pay for chiropractic spinal manipulation (98941) 
and mechanical traction therapy provided on February 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on February 3, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z Code identifier should be placed adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 01936 provided on January 24, 
2020. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 01936 is anesthesia for percutaneous image guided 
procedures on the spine and spinal cord; therapeutic. 
 
We find that CPT code 01936 is not supported in the medical record. Specifically, most minor pain procedures 
do not require anesthesia care other than local anesthesia. This is payable with modifier G9 monitored 
anesthesia care. The anesthesia record submitted is complete. Therefore, the documentation does not support 
that the anesthesia services provided were necessary. Based on this information, we decided that Medicare 
rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not 
have to pay for the anesthesia services coded 01936 provided on January 24, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from February 26, 2020 
to March 5, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
required no nursing services which would be considered skilled services by Medicare on the dates of service in 
question. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from February 26, 2020 to March 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care from March 11, 
2020 through March 14, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that the billing is incorrect and 
it should not be this much. 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 shows that you were admitted on March 11, 2020 and discharged on March 14, 2020. You 
were asked to pay a $200 copayment per day from March 11, 2020 through March 13, 2020, days 1-3 of your 
inpatient hospital care. You were discharged on March 14, 2020 and there was no copayment charge for the 
day of discharge. Per your contract there is a $200 copayment per day required for days 1-5. 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 from March 11, 2020 through March 14, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the CT scan provided on February 25, 
2019. 
 
You asked the Plan to waive the coinsurance for the CT scan. You say that you do not feel that you owe the 
Plan any copayment amount. 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 20% 
coinsurance for all other diagnostic and nuclear medicine radiological services.  
 
You have been asked to pay $25.99 which is 20% coinsurance for the CT scan. The allowed amount is 
$129.95. ($129.95 x 20% = $25.99). The CT scan 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 waive the copayment for the CT scan 
provided on February 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the surgery services provided on January 
15, 2020. 
 
You asked the Plan to waive the coinsurance for the surgery services. You say that you are on a fixed income 
and this is a financial hardship. 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 20% 
coinsurance for in-network Medicare-covered physician services received while an inpatient during a 
Medicare-covered hospital stay.  
 
You have been asked to pay a total of $514.81 which is 20% of the allowed amounts for the surgery services. 
The total allowed amount is $2,574.07. ($2,574.04 x 20% = $514.81). The surgery services fall within the 
?Inpatient hospital 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 coinsurance for the surgery 
services provided on January 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 29846 billed for date of service July 10, 2019. 
 
You asked the Plan to pay for CPT code 29846. You say that the records provided support the service in 
dispute. The Plan denied your request. The Plan says the operative report did not include documentation of 
surgical wrist arthroscopy excision and/or repair of triangular fibrocartilage and/or joint debridement. The Plan 
says that the code in dispute cannot be verified. 
 
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 CPT code 29846 is Arthroscopy, wrist, surgical; excision 
and/or repair of triangular fibrocartilage and/or joint debridement. 
 
We find that CPT code CPT code 29846 is not supported in the medical record. Specifically, the operative note 
narrative does not document the description of the CPT code in dispute was performed on the date of service 
billed. Based on this information, we decided that Medicare rules for coverage of CPT code 29846 have not 
been met. Therefore, we decided that the Plan does not have to pay for CPT code 29846 billed for date of 
service July 10, 2019.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to make additional payment for the periodic oral evaluation and prophylaxis. We 
decided that the Plan does not have to pay in full for the first intraoral periapical x-ray, additional intraoral 
periapical x-ray, bitewings, periodic oral evaluation, and prophylaxis.  
 
 
You asked the Plan to pay in full for the first intraoral periapical x-ray, additional intraoral periapical x-ray, 
bitewings, periodic oral evaluation, and prophylaxis. You say that in your documents from the Plan, it shows a 
$0.00 copay for dental services. The Plan says that first intraoral periapical x-ray, each additional intraoral 
periapical x-ray, and bitewings are not covered benefits. The Plan also says that the treating provider is OON, 
and you are responsible for a 20% coinsurance for the periodic oral evaluation and prophylaxis. 
 
We decided that the Plan has to make additional payment for the periodic oral evaluation and 
prophylaxis.  
 
The contract says that the Plan does not allow providers to add additional separate charges, called balance 
billing. 
 
The record shows that you received a partial payment for the periodic oral evaluation and prophylaxis, and you 
were held responsible for paying a 20% coinsurance plus the difference between the provider's billed amount 
and the Plan's allowed amount. The contract clearly states that you are responsible for a 20% coinsurance for 
these services when they are received OON. The contract also says that they do not allow provider to balance 
bill you. The contract does not say that you can be held responsible for the difference between the billed 
amount and allowed amount. Therefore, we decided that the Plan has to make additional payment for the 
periodic oral evaluation and prophylaxis.  
 
We also decided that the Plan does not have to pay in full for the first intraoral periapical x-ray, 
additional intraoral periapical x-ray, bitewings, periodic oral evaluation, and prophylaxis. 
 
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, first intraoral periapical x-ray, each 
additional intraoral periapical x-ray, and bitewings are not among those covered under this benefit. The 
contract also clearly states that you must pay a 20% coinsurance for dental services that are received OON. 
Therefore, we decided that the Plan does not have to pay in full for the first intraoral periapical x-ray, 
additional intraoral periapical x-ray, bitewings, periodic oral evaluation, and prophylaxis. 
 
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.