Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered on April 14, 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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 lumbar-sacral orthosis (LSO) rendered on April 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination (71046) provided on June 8, 
2020. 
 
You asked the Plan to pay for the radiologic examination (71046). 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. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71046 
has a bundled relationship with code 32555 and cannot be paid as billed. This code cannot be paid as a separate 
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided 
that the Plan does not have to pay for the radiologic examination (71046) provided on June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $35 copayment charged for specialist services provided on 
February 18, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment is a contractual obligation. 
 
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 $35 
copayment for specialist services.  
 
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 $35 copayment charged for specialist services provided on February 18, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Electro convulsive Therapy provided out of network on 
September 5, 2019. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says your out of network provider did not submit medical records to show this 
treatment was medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. You did not have prior authorization for out of network care. Your provider was 
asked to submit medical records to demonstrate medical necessity for this treatment but did not response.  
Therefore, we decided that the Plan does not have to pay for Electro convulsive Therapy provided out of 
network on September 5, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 8, 2020. 
 
You asked the Plan to pay for the laboratory services. 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. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 8, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $260 copayment charged for ambulance services provided 
on May 17, 2020. 
 
You asked the Plan to waive this copayment. You say that you did not think the copayment would be this high. 
The Plan denied your request. The Plan says this copayment was charged per your Plan contract agreement. 
 
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 $260 for 
ambulance transport. 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 $260 copayment charged for ambulance services provided on 
May 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant 360 testing provided to the enrollee on October 3, 
2019. 
 
You asked the Plan to pay this claim. You say that these services should be paid by the Plan. The Plan denied 
your request. The Plan says The Plan says this is an administrative determination for coding and is not based on 
clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use 
of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field. 
 
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 claim is missing the main code 
and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of 
this claim have not been met. Therefore, we decided that the Plan does not have to pay for Guardant 360 testing 
provided to the enrollee on October 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waivethe $325 copayment for ambulance transport provided on April 4, 2020.You askedthe Plan to waivethis copayment. You say that this copayment is high for the distance traveled in the ambulance.The Plan denied your request. The Plan says this copayment is a contractual obligation.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 $325 copayment for ambulance transport. 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 waivethe $325 copayment for ambulance transport provided on April 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on May 19, 2020. 
 
You asked the Plan to pay for this service. You say that the Plan should cover these services. The Plan denied 
your request. The Plan says you did not have prior authorization for out of network 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 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 out of network physician services provided on May 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic testing (D0431), the localized 
delivery of microbial agents (D4381 x 4), gingival irrigation (D4921 x 2), and the drugs or medicaments 
(D9630 x 2) provided from June 9, 2020, to June 10, 2020. 
 
You asked the Plan to pay for the dental services. You say that you wanted to reduce the amount of contact that 
you had with other people due to COVID-19 as well as the amount of antibiotics you had to take in addition to 
what you were already on. You say that you had to return the next day due to have treatment on the other side 
of your mouth per insurance guidelines. The Plan denied your request. The Plan says the adjunctive pre-
diagnostic testing, gingival irrigation, and drugs or medicaments are not listed as covered service. The Plan 
says that localized delivery of microbial agents cannot be billed the same day as scaling and root planing. The 
Plan also says that you are responsible for the full cost of the services that are not covered by the plan and 
limitations. 
 
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. While localized delivery of microbial agents is listed as a covered 
service, the record shows that you received this service on the same day as scaling and root planing. The 
Evidence of Coverage clearly states that localized delivery of microbial agents is not covered when billed the 
same day as the scaling and root planing. Therefore, we decided that the Plan does not have to pay for the 
adjunctive pre-diagnostic testing (D0431), the localized delivery of microbial agents (D4381 x 4), gingival 
irrigation (D4921 x 2), and the drugs or medicaments (D9630 x 2) provided from June 9, 2020, to June 10, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe endodontic therapy provided on May 11, 2020 by anOON provider.You asked the Plan to pay forthe endodontic therapy. You say that the in-network coverage rates should apply.The Plan denied your request. The Plan says the benefits for this service have been satisfied and the frequency limitation has been exceeded.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, root canal is limited to one procedure per calendar year. The record shows that you received two root canals on May 11, 2020, one of which was covered by the Plan, and your root canal benefit has been exhausted.Therefore, wedecided that the Plan does not have to pay forthe endodontic therapy provided on May 11, 2020 by an OON provider.Your complaint about being dissatisfied with the Plan's coverageis not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided by a facility from February 
17, 2020 to February 19, 2020. 
 
You asked the Plan to pay for self-administered drugs under Medicare Part B. You say that this claim should be 
covered by the Plan. The Plan denied your request. The Plan says claims for self-administered drugs should be 
submitted to Medicare Part D. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
by a facility from February 17, 2020 to February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection(s), anesthetic agent(s) and/or steroid; genicular 
nerve branches, including imaging guidance, when performed (CPT Code 64454) provided on March 10, 2020, 
by an out-of-network provider. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not necessary and are considered experimental or investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is an experimental/ investigational procedure and there are on-going clinical trials to define 
the role of this procedure in the treatment of knee osteoarthritis.  The patient is not in a clinical trial. Therefore, 
the request was not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging 
guidance, when performed (CPT Code 64454) provided on March 10, 2020, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe magnetic resonance imaging (MRI) you had on July 8, 2020.You asked the Plan to waive the coinsurance forthe MRI. You say that you were unaware of the cost for MRIs.The Plan denied your request. The Plan says you were charged this coinsurance correctly.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 diagnostic radiology services. You have been asked to pay 20% coinsurance for the MRI. The MRI falls within the diagnostic radiology services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance forthe magnetic resonance imaging (MRI) you had on July 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on 
April 9, 2020. 
 
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration 
because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating 
room throughout the duration of the procedure. The Plan denied your request. The Plan says payment for this 
service is the responsibility of the facility to any vendor. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier 
other than the facility or hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pump assembly and operation have not been met. Specifically, payment for this service is 
included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, 
we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on 
April 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forlarger wheels on an ultralight walker provided on May 1, 2020.You asked the Plan to pay forthe larger wheels. You say that you are requesting reimbursement of services rendered. You state you were unable to walk down the streets over raised and cracked pavements which cause you to fall.The Plan denied your request. The Plan says the upgrade is not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  Larger wheels are a convenience item and not covered. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pay forlarger wheels on an ultralight walker provided on May 1, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waivethe $90 copayment charged for emergency room services provided on April 28, 2020.You asked the Plan to waivethis copayment. You say that you would like this copayment waived.The Plan denied your request. The Plan says this copayment is a contractual obligation.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 $90 copayment for emergency room services. 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 waivethe $90 copayment charged for emergency room services provided on April 28, 202
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for preventative immunizations provided to the enrollee on 
December 23, 2019. 
 
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. 
The Plan says preventative immunizations must be submitted to the enrollees Medicare Part D carrier. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide this claim. The Plan 
follows the same rules. The records do not show that the enrollee had been injured or directly exposed to any 
illness related to this claim. Therefore, we decided that the Plan does not have to pay for preventative 
immunizations provided to the enrollee on December 23, 2019.  
 
Benefits for this claim 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management service (99358) provided on March 5, 
2020. 
 
You asked the Plan to pay for the evaluation and management service. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says that this CPT code 
should be used to report evaluation and management services that do not involve direct patient care. 
 
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 99358 is prolonged evaluation and management service before and/or after direct patient care; first hour. 
 
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 evaluation and management service. Our reviewer says 
that CPT code 99358 meets criteria for billing and reimbursement consideration. Our reviewer found the 
provider documents 75 minutes was spent face to face with member and family member, and, an additional 70 
minutes was spent with non-face-to-face patient care. The provider spent more than 30 minutes for non-face-to-
face patient care and would be reported separately. 
 
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 evaluation and management service have been met. Therefore, we decided 
that the Plan has to pay for the evaluation and management service (99358) provided on March 5, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse forthe cataract lens implant purchased on February 19, 2020.You asked the Plan to reimburse forthe cataract lensimplant. You say that you would like to be reimbursed the amount as a standard IOL would cost.The Plan denied your request. The Plan says premium intraocular cataract lenses are not covered under Medicare, only standard lens are covered.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. This upgrade is not covered. Your EOC states that covered services include: one pair of standard therapeutic (prescription) eyeglasses with standard frames or contact lenses after each cataract surgery that includes insertion of an intraocular lens.Therefore, we decided that the Plan does not have to reimburse forthe cataract lens implant purchased on February 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) and a knee orthosis with 
suspension sleeve (L1833, L2397) provided to the enrollee on February 5, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says there is no itemized billing/shipping invoice to verify the services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a proof of delivery to support medical necessity for the supplies provided in this 
case. There is no itemized billing/shipping invoice to verify the services billed. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a lumbar-sacral orthosis (L0648) and a knee orthosis with suspension sleeve 
(L1833, L2397) provided to the enrollee on February 5, 2020.