Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a chest x-ray (71045) provided on March 10, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because this claim 
was denied as a duplicate in error. The Plan denied your request. The Plan says that this claim is an exact 
duplicate of another claim that has already been processed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has failed to forward the initial claim or explanation of 
benefits to show that this claim is an exact duplicate. It is the burden of the Medicare Health Plan to 
substantiate the denial with evidence. The denial is not substantiated and we must find in your favor. Therefore, 
we decided that the Plan has to pay for a chest x-ray (71045) provided on March 10, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 12, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the member's primary care physician did not refer these 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 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 home health services provided on March 12, 2020 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis (L1833) provided January 22, 2020. 
 
You asked the Plan to pay for the orthosis. You say that kindly find the attached medical records that proves 
the medical necessity and reprocess the claim. The Plan denied your request. The Plan says this is not 
medically necessary because the records do not support the service. 
 
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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation in the case file does not support that the requested knee orthosis was 
medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established 
by the LCD. There is no objective documentation of joint laxity. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for knee orthosis (L1833) provided January 22, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on February 8, 
2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99283 is not supported. 
 
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 99283 is Level 3 emergency department visit for 
evaluation and management of patient with problem of moderate severity, including expanded problem-focused 
history and physical examination, and medical decision-making of moderate complexity. 
 
We find that CPT code 99283 is not supported in the medical record. Specifically, there is no documentation of 
a Level 3 emergency department visit for evaluation and management. 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 emergency room (ER) services rendered on February 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the detailed and extensive problem focused oral evaluation 
(D0160) provided on April 9, 2020. 
 
You asked the Plan to pay for the detailed and extensive problem focused oral evaluation. You say that a Plan 
representative advised that there would not be a waiting period to add the dental rider to your plan, and it would 
be effective the next day. You also say that when you called in April to activate the dental rider, you were 
advised that there was a 1 month waiting period before it would become effective. The Plan denied your 
request. The Plan says this service is not a covered benefit under your dental plan. 
 
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 
detailed and extensive problem focused oral evaluation (D0160) provided on April 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ice machine cold and compression therapy unit. 
 
You asked the Plan to pay for the ice machine cold and compression therapy unit. You say that the requested 
device would help speed up the enrollee's recovery and get him ready for physical therapy. The Plan denied 
your request. The Plan says the item in dispute 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.   
 
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 for an ice machine cold and compression therapy unit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
March 31, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says their review of the documentation determined that the billed services were not 
supported. 
 
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 valid proof of delivery to support medical necessity for the supplies provided in 
this case. There is no signed delivery ticket, proof of delivery, or itemized invoice. 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 (L0650) provided to the enrollee on March 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace provided on March 31, 2020. 
 
You asked the Plan to pay for the back brace. You say that sufficient documentation has been submitted to 
support payment of this claim. The Plan denied your request. The Plan says there is no valid proof of delivery 
for the billed date of service. 
 
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 valid proof of delivery for the supplies provided in this case. The delivery 
confirmation submitted does not match the billed date of service, nor does the date on the invoice. 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 the back brace provided on March 31, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services provided by Visiting Angels from 
January 13, 2020 to January 16, 2020. 
 
You asked the Plan to pre-approve home health services. You say that no in-network providers would provide 
the services the enrollee needed. The Plan denied your request. The Plan says this provider is not certified for 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The provider of these services is not enrolled in Medicare. Based on 
this information, we decided that Medicare rules for coverage of home health services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve home health services provided from January 13, 2020 to January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on March 13, 2020. 
 
You asked the Plan to waive the coinsurance for DME. You say that you were not informed of the charges. The 
Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct 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 DME and related supplies.  
 
You received DME on March 13, 2020. The allowed amount is $345.83 and 20% of that is $69.17.  
 
You have been asked to pay the total coinsurance amount of $69.17 for DME. DME falls within the DME and 
related supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for DME provided on March 
13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided on February 26, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the member's primary care physician did not refer these 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 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 specialist services provided on February 26, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 24, 2018. 
 
You asked the Plan to pay for dental services provided by a provider who opted out of Medicare. You say that 
you did not realize the provider had opted out of Medicare. The Plan denied your request. The Plan says 
services from Medicare op-out providers are not covered under the enrollee's plan. 
 
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 
dental services provided on August 24, 2018.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on December 
6, 2019. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct 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 $220 
copayment for ambulance services.  
 
You have been asked to pay a $220 copayment for ambulance services. Ambulance services fall within the 
ambulance 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 copayment for ambulance services 
provided on December 6, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on May 4, 2020. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you feel that the colonoscopy 
should be considered as preventative because you did not have any polyps removed. The Plan denied your 
request. The Plan says the claims were processed correctly and you are being charged the correct 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 $325 
copayment for outpatient surgery.  
 
The medical records show that you received a colonoscopy on May 4, 2020 due to rectal bleeding. Therefore, 
the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $325 copayment.  
 
You have been asked to pay a $325 copayment for a colonoscopy. A colonoscopy falls within the outpatient 
surgery 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 a colonoscopy provided on 
May 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an inpatient hospital stay provided from 
April 10, 2020 to April 17, 2020. 
 
You asked the Plan to waive the coinsurance for an inpatient hospital stay. You say that you disagree with the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct 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 35% 
coinsurance for out-of-network inpatient hospital care.  
 
You have been asked to pay $7,447.43, which is less than the 35% coinsurance for an out-of-network inpatient 
hospital stay. An inpatient hospital 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 coinsurance for an inpatient hospital stay provided from April 10, 2020 to April 17, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fracture treatment (20692, 27825, 27870) provided on 
October 29, 2019. 
 
You asked the Plan to pay for fracture treatment. You say that these codes are documented. The Plan denied 
your request. The Plan says these codes are not supported for the billed date of service. 
 
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 20692, 27825, and 27870 is not supported in the medical record for the billed date of 
service, October  29, 2019. Specifically, the operative note in the file is dated October 31, 2019. It cannot be 
verified that these services were performed on October 29, 2019. Based on this information, we decided that 
Medicare rules for coverage of fracture treatment have not been met. Therefore, we decided that the Plan does 
not have to pay for fracture treatment (20692, 27825, 27870) provided on October 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Visolux Digital XL FHD provided on December 13, 2019. 
 
You asked the Plan to pay for the Visolux Digital XL FHD. You say that you were advised that the device 
would be covered, as you are blind and it helps you to read. The Plan denied your request. The Plan says low 
vision aids are not covered for Medicare members. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover low vision aids. 
 
The item you asked the Plan to pay for is considered a low vision aid. Therefore, we decided that the Plan does 
not have to pay for a Visolux Digital XL FHD provided on December 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs provided on March 
24, 2020. 
 
You asked the Plan to waive the coinsurance for chemotherapy drugs. You say that you have previously paid 
less for this service. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for chemotherapy drugs.  
 
The allowed amount of the claim is $4,386.05, resulting in a coinsurance obligation of $877.20 for 
chemotherapy drugs ($4,386.05 x 20% = $877.20). 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 on March 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the CT scan of the chest provided on 
April 3, 2020 billed with code 71250. 
 
You asked the Plan to pay for the CT scan interpretation. You say that this was denied as duplicate in error and 
should be paid. The Plan denied your request. The Plan says this code is a Column 2 code billed without a 
modifier for this date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that when a PTP edit pair is billed, only the Column I 
code is payable unless a clinically appropriate modifier is appended to the Column 2 code. 
 
CPT code 71250 has is a Column 2 code in relation to code 71275 which was provided and billed by the same 
physician on this date of service. No modifier was appended to indicate this was a separate encounter. No 
records from the other imaging study were provided. Therefore, we decided that the Plan does not have to pay 
for the interpretation of the CT scan of the chest provided on April 3, 2020 billed with code 71250.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81162, 81201, 81203, 81242, 
81292, 81294, 81295, 81297, 81298,81300, 81317, 81319, 81404, 81405, 81406, 81407 and 81408 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. The Plan denied your request. The Plan says the billed services 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 81162, 81201, 81203, 81242, 81292, 81294, 81295, 81297, 81298,81300, 81317, 
81319, 81404, 81405, 81406, 81407 and 81408 is not supported in the medical record. Specifically, the 
documentation does not support evidence of an established relationship between the enrollee and the ordering 
physician. 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 
81162, 81201, 81203, 81242, 81292, 81294, 81295, 81297, 81298,81300, 81317, 81319, 81404, 81405, 81406, 
81407 and 81408 provided on January 8, 2020.