Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive procedure (D1999) provided on 
May 4, 2020.  
 
You asked the Plan to pay for the unspecified preventive procedure (D1999). You say that this was a cleaning 
and the root canal was checked. You say that you don't understand why a recommended cleaning wouldn't be 
paid. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
unspecified preventive procedure (D1999) provided on May 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy and physical therapy provided from 
January 3, 2020 through February 3, 2020. 
 
You asked the Plan to pay for occupational therapy and physical therapy. You say that the provider was not 
notified that the enrollee's plan was changed. You say that the therapy services were warranted and necessary. 
The Plan denied your request. The Plan says services received at a VA facility are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may not be made for items and services 
furnished by a provider of service or agency of the Federal government. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of occupational therapy and physical therapy have not been met. Therefore, we decided that the Plan 
does not have to pay for occupational therapy and physical therapy provided from January 3, 2020 through 
February 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital care from July 1, 2020 to discharge, 
for the enrollee. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay was medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
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 pre-approve 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 with presentation with only symptoms and no abnormal vital signs or 
evidence of infectious etiology, patient was appropriate for observation and then admission if they did not 
improve. This patient did not meet criteria for admission at the time of admission. 
 
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 pre-approve inpatient hospital care from July 1, 2020 to discharge, for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care from April 10, 2019 
through April 16, 2019. 
 
You asked the Plan to waive the copayment for inpatient hospital 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 2019 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 April 10, 2019 and discharged on April 16, 2019. You 
were asked to pay a $350 copayment per day from April 10, 2019 through April 14, 2019, days 1- of your 
inpatient stay. There were no copayment charges from April 15, 2019, day 6 of your inpatient hospital care 
until your day of discharge April 16, 2019. Per your contract there is a $350 copayment per day required for 
days 1-5 for in-network inpatient hospital care. 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 April 10, 2019 through April 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapy and specialist services provided on 
February 25, 2020 by an out-of-network provider. 
 
You asked the Plan to waive the copayment 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).  
 
You are responsible for a $25.00 copayment for each Medicare-covered therapy visit and $30.00 copayment for 
services obtained from a specialist. Review of the file shows that you received both services at the same visit 
and providers may ask you for more than one cost share payment if you get more than one service at an 
appointment. 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 therapy and specialist services provided on 
February 25, 2020 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT codes 88342 and 88341 provided on July 29, 2019. 
 
You asked the Plan to pay for CPT codes 88342 and 88341. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. Medicare payment rules say procedure codes that are incorrectly 
reported with other procedure codes as a result of the misuse of the column two code with the column one code 
are not payable as there are limited circumstances when the column two code may be reported on the same date 
of service as the column one code. In this case, CPT codes 88342 and 88341 are column two codes and cannot 
be billed with column one code, 80360. Therefore, we decided that the Plan does not have to pay for CPT 
codes 88342 and 88341 provided on July 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on January 7, 2020. 
 
You asked the Plan to pay for the radiology services. The Plan denied your request. The Plan says you must 
receive your care from a network provider. In most cases, care you receive from an out-of-network provider 
will not be covered. If you need medical care that Medicare requires our plan to cover and the providers in our 
network cannot provide this care, you can get this care from an out-of-network provider. You or your PCP 
must obtain authorization from the plan prior to seeking care. 
 
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. 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 radiology services provided on January 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on October 23, 
2019. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you were not told how much 
your copay would be. 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 $400 
copayment for per date of service for outpatient surgery provided in an outpatient hospital facility under the 
Select Rx plan.  
 
You have been asked to pay a $400 copayment for outpatient surgery. Outpatient surgery falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 outpatient surgery provided on 
October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent; other peripheral nerve 
or branch (CPT Code 64640) 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is 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 pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the LCD specifically states: "Radiofrequency ablation used for sacro-iliac joint pain is 
considered not medically necessary/investigational whether performed using traditional, cooled, or pulsed 
radiofrequency." This is because of the very wide variability of efficacy reported in the peer-reviewed 
literature. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent; other peripheral nerve or branch (CPT Code 64640)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chair lift purchased on March 30, 2020 from a non-
Medicare provider. 
 
You asked the Plan to pay for the DME. You say that your doctor prescribed and requested the chair lift. The 
Plan denied your request. The Plan says this provider does not participate with Medicare and per Medicare 
guidelines if your doctors or suppliers aren't enrolled then Medicare won't pay for the claims they submit. 
 
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 DME from a non-Medicare provider on March 30, 2020. The rules 
say that 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 chair lift purchased on 
March 30, 2020 from a non-Medicare provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 19, 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 entered adjacent 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 April 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 88305, 88307, 88341, and 
88342 provided on November 1, 2019. 
 
You asked the Plan to pay for the laboratory 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 supported by the documentation. 
 
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 codes 88305, 88307, 88341, and 88342 are not supported in the medical record. Specifically, 
the pathology report submitted indicates a difference in collected date and billed date. Collected date is October 
29, 2019, whereas the billed date is November 01, 2019; therefore, the billed services cannot be verified. Based 
on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 88305, 88307, 
88341, and 88342 provided on November 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapy and specialist services provided on 
March 10, 2020 by an out-of-network provider. 
 
You asked the Plan to waive the copayment 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).  
 
You are responsible for a $25.00 copayment for each Medicare-covered therapy visit and $30.00 copayment for 
services obtained from a specialist. Review of the file shows that you received both services at the same visit 
and providers may ask you for more than one cost share payment if you get more than one service at an 
appointment. 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 therapy and specialist services provided on 
March 10, 2020 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the services provided from January 28, 
2020 through February 25, 2020. 
 
You asked the Plan to waive the copayment for the services. You say that you asked the front desk services if 
the services would be covered and they informed you that it would be covered. The Plan denied your request. 
The Plan says the claims were processed accordingly with your 2019 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 on January 28, 2020, you had debridement, subcutaneous tissue (11042) with a 
$225.00 copayment. On February 11, 2020, you had hospital outpatient clinic visit for assessment and 
management of a patient (G0463) with an allowable of $117.74 which was less than the $225 copayment so, 
you were assessed the lesser amount of $117.74. On February 25, 2020 you had a hospital outpatient clinic visit 
for assessment and management of a patient (G0463) with an allowable of $117.74 which was less than the 
$225 copayment so, you were assessed the lesser amount of $117.74. These services total $460.48 in 
copayments. 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 services provided from January 28, 
2020 through February 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from January 19, 
2020 to January 21, 2020. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you believe you should have a 
$0 copayment. 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 $250 
copayment per day for days 1-7 for each inpatient stay.  
 
You have been asked to pay a $750 copayment per day for your three day inpatient stay. An inpatient stay falls 
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 copayment for 
an inpatient stay provided from January 19, 2020 to January 21, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to the enrollee from April 3, 2020 
through April 21, 2020. 
 
You asked the Plan to pay for the services. You say that the claims should be paid. The Plan denied your 
request. The Plan says the facility claims billed with the incorrect type of bill and once they receive a corrected 
claim they will revisit this claim for reprocessing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The claim cannot be paid as billed due to an error with the type of bill 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 the services provided to the enrollee from April 3, 2020 through April 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on 
January 31, 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 $380 
copayment per day for days 1-5 for covered hospital care.  
 
You have been asked to pay $380 ($380 copayment x 1 day) for inpatient hospital care 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 inpatient hospital care provided on January 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pharmacogenomics screening testing. 
 
You asked the Plan to pre-approve genetic testing. You say that you are requesting authorization for these tests. 
The Plan denied your request. The Plan says the denial of authorization for these tests is correct, because these 
tests are not covered for the requested 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 tests at issue in this appeal, genetic testing, are being requested for screening purposes. Medicare does not 
cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pre-
approve pharmacogenomics screening testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 64451 provided on January 30, 2020. 
 
You asked the Plan to pay for CPT code 64451. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Medicare payment rules say procedure codes that are incorrectly 
reported with other procedure codes as a result of the misuse of the column two code with the column one code 
are not payable as there are limited circumstances when the column two code may be reported on the same date 
of service as the column one code. In this case, CPT code 64451 is a column two code and cannot be billed 
with column one code, 20553. Therefore, we decided that the Plan does not have to pay for CPT code 64451 
provided on January 30, 2020.