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

 
We decided that the Plan does not have to pay for drug testing provided on June 19, 2019. 
 
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory 
requisition form. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the documentation submitted does not support the tests as billed on this claim. 
 
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 lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan 
does not have to pay for drug testing provided on June 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown provided on February 5, 2020. 
 
You asked the Plan to pay for the crown. You say that you spoke with a Plan representative who advised that 
you had basic dental coverage that would cover 20% of the dental cost. The Plan denied your request. The Plan 
says this dental service is not covered by your medical plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. The Plan also says that optional supplemental benefits are available that covers certain dental 
services, but it is an extra benefit that you will have to pay an extra monthly premium for. Therefore, we 
decided that the Plan does not have to pay for the crown provided on February 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 28, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says there is no 
authorization on file for the services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
radiology services at issue. We found no exception that would require the Plan to pay for these OON services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on December 28, 
2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hip x-ray (73522) provided on January 9, 2020. 
 
You asked the Plan to pay for the hip x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation submitted does not support the 
service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 73522 is radiologic examination, hips, bilateral, with 
pelvis when performed; 3-4 views. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the hip x-ray. Our reviewer says that CPT code 73522 does 
not meet criteria for billing or reimbursement consideration. Our reviewer found the radiology report 
documents 2 views were performed on bilateral hips with pelvis. There is a more appropriate code for this 
procedure. 
 
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 hip x-ray have not been met. Therefore, we decided that the Plan does not 
have to pay for a hip x-ray (73522) provided on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a Zoster (shingles) vaccine (90750) provided on March 11,
2020.
You asked the Plan to pay for a shingles vaccine. You say that this should be covered. The Plan denied your
request. The Plan says this is covered under Medicare Part D.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine.
The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine.
Therefore, we decided that the Plan does not have to pay for a Zoster (shingles) vaccine (90750) provided on
March 11, 2020.
Benefits for a shingles 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs provided from January 28, 2020 to March 9, 2020. You asked the Plan to waive the coinsurance for chemotherapy drugs. You say that you are requesting payment of these amounts. The Plan denied your request. The Plan says the coinsurance amounts you are being charged are 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 20% coinsurance for in-network chemotherapy drugs. The allowed amounts of these drugs total $5,735, resulting in a coinsurance obligation of $1,147. You have been asked to pay 20% coinsurance for chemotherapy drugs. Chemotherapy drugs 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 coinsurance for chemotherapy drugs provided from January 28, 2020 to March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT codes 99152, 99153, 41112, and 21031 provided on 
January 8, 2020. 
 
You asked the Plan to pay for CPT codes 99152, 99153, 41112, and 21031. You say that you would like the 
Plan to reconsider their denial of payments The Plan denied your request. The Plan says the medical records do 
not support the billing of CPT codes 99152, 99153, 41112, and 21031. 
 
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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
The CPT Code Manual definition of code 41112 is Excision of lesion of tongue with closure; anterior two-
thirds. 
 
The CPT Code Manual definition of code 21031 is Excision of torus mandibularis. 
 
We find that CPT codes 99152, 99153, 41112, and 21031 are not supported in the medical record. Specifically, 
CPT code 99152 is not supported because the medical record does not contain evidence that moderate sedation 
was performed with the presence of an independent trained observer. Medicare says that CPT code 99153 is a 
Type 1 add-on code and must be reported with a proper primary code. In this case, CPT code 99153 was billed 
with a primary procedure code that is found to not be supported for payment. Medicare does not pay for add-on 
codes that are not reported with a proper primary code eligible for payment. Lastly, the file does not contain a 
surgical procedure report, only a pathology report. Without the surgical procedure report we are unable to 
verify if the surgical procedure was coded correctly with CPT codes 41112 and 21031. Based on this 
information, we decided that Medicare rules for coverage of CPT codes 99152, 99153, 41112, and 21031 have 
not been met. Therefore, we decided that the Plan does not have to pay for CPT codes 99152, 99153, 41112, 
and 21031 provided on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an annual wellness visit provided on December 19, 2019.
You asked the Plan to pay for annual wellness visit. You say that you had a previous visit with another doctor
that you were not satisfied with, and this provider needed to evaluate you as a new patient. The Plan denied
your request. The Plan says the denial of payment for this service is correct, because you received an annual
wellness visit on March 19, 2019 and therefore 12 months had not passed before this visit was provided.
The Plan must follow Medicare rules. Medicare rules say that an annual wellness visit is covered once every 12
months.
We looked at the file and Medicare rules. You received a previous annual wellness visit on March 19, 2019;
therefore 12 months had not passed before this annual wellness visit was performed. Based on this information,
we decided that Medicare rules for coverage of annual wellness visit have not been met. Therefore, we decided
that the Plan does not have to pay for an annual wellness visit provided on December 19, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services with a memory care unit. You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet Medicare criteria for continued SNF care in a different facility. The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before the enrollee's last covered day. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services with a memory care unit. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on February 12, 
2020. 
 
You asked the Plan to pay for the psychotherapy services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the services were not pre-authorized or emergent. 
There were network providers available. 
 
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 service 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 psychotherapy services (90832) provided on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 76498 provided on March 23, 2020.
You asked the Plan to pay for CPT code 76498. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 76498 is Unlisted magnetic resonance procedure (eg,
diagnostic, interventional).
We find that CPT code 76498 is not supported in the medical record. The file shows that the member received
an MRI of the pelvis without contrast. This procedure has a specific CPT code. Based on this information, we
decided that Medicare rules for coverage of CPT code 76498 have not been met. Therefore, we decided that the
Plan does not have to pay for CPT code 76498 provided on March 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit on February 27, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you would like for your copay to
be waived. 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 $15
copayment for each in-network Medicare-covered visit with a PCP.
You have been asked to pay a $15 copayment for an office visit. An office visit falls within the
Physician/Practitioner services, including doctor's office visits, benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for an office visit on February 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the items are necessary. The Plan 
denied your request. The Plan says non-reusable hygiene items that are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance you took from Mexico to Florida provided 
on January 22, 2020. 
 
You asked the Plan to pay for the air ambulance. You say that the air ambulance was for an emergency and 
your benefit books show that it is covered. The Plan denied your request. The Plan says transportation back to 
the United States from another country is not covered. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the air ambulance have not been met. Transportation back to the United States from another 
country is not covered. Therefore, we decided that the Plan does not have to pay for the air ambulance you took 
from Mexico to Florida provided on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 10, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must
receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for physician's services provided on January 10, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
November 6, 2019 to November 7, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you were admitted for
observation and this should be covered in full. 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 $50
copayment for each emergency room visit.
You have been asked to pay a $50 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency care" visit benefit category. The record shows you were admitted to observation in the
emergency room and not as an inpatient to the hospital.
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 emergency room visit provided on November 6, 2019 to
November 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing - four or more teeth per 
quadrant, UL and LL (D4341 x 2), resin-based composite - two surfaces, posterior, tooth #13 (D2392), crown - 
porcelain fused to high noble metal (D2750 x 2) and core buildup, including any pins when required (D2950) 
provided from January 21, 2020 through February 25, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says the claims were processed accordingly with your 
2020 EOC 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. 
 
Review of the file shows that you had crown - porcelain fused to high noble metal (D2750 x 2) 
and core buildup, including any pins when required (D2950) on February 25, 2020. You have coverage for 
preventative and comprehensive dental coverage. However, there is no coverage for crowns. 
 
Review of the file shows that you had periodontal scaling and root planing - four or more teeth per quadrant 
(D4341 x 2) of the upper right quadrant and lower right quadrant. Your Plan paid for these services. You then 
had periodontal scaling and root planing - four or more teeth per quadrant (D4341 x 2) of the upper left 
quadrant and lower left quadrant that was denied for coverage because you exhausted your benefit on January 
21, 2020. Your EOC states, "Periodontal scaling and root planning (limited to one (1) per quadrant every 
twenty-four (24) months.)." 
 
Review of the file shows that you had resin-based composite - two surfaces, posterior, tooth #13 (D2392) on 
February 18, 2020. The Plan paid $38 and you are responsible for $83 because you exhausted your $500 
comprehensive allowance. Therefore, we decided that the Plan does not have to pay for periodontal scaling and 
root planing - four or more teeth per quadrant, UL and LL (D4341 x 2), resin-based composite - two surfaces, 
posterior, tooth #13 (D2392), crown - porcelain fused to high noble metal (D2750 x 2) and core buildup, 
including any pins when required (D2950) provided from January 21, 2020 through February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fitting of spectacle mounted low vision aid, single element system (92354) to be performed by an out-of-network provider.
You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says you do not have out-of-network benefits and low vision aids are excluded from coverage by Medicare and your plan under any condition.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Furthermore, low vision aids are excluded from coverage by Medicare and your plan under any condition. Therefore, we decided that the Plan does not have to pre-approve fitting of spectacle mounted low vision aid, single element system (92354) to be performed by an out-of-network provider.