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

 
We decided that the Plan does not have to pay for the crowns and core buildup provided on November 18, 
2019. 
 
You asked the Plan to pay for the crowns and core buildup. You say that you treated the enrollee so she 
wouldn't lose any teeth. You say that you don't understand how this isn't payable under the policy. The Plan 
denied your request. The Plan says the services are not covered. 
 
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. Therefore, we decided that the Plan does not have to pay for the crowns and core buildup 
provided on November 18, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (HCPCS G0480) provided to the 
enrollee on March 13, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0480 (1 Unit) remains 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 HCPCS code G0480 is "Drug test(s), definitive, utilizing (1) 
drug identification methods able to identify individual drugs and distinguish between structural isomers (but 
not necessarily stereoisomers), including, but not limited to, GC/MS (anytype, single or tandem) and LC/MS 
(any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA,EMIT, FPIA) and enzymatic 
methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in 
all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3)method or 
drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations 
and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 
drug class(es), including metabolite." 
 
We find that HCPCS code G0480 is not supported in the medical record. Specifically, the place of service on 
the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects 
a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's 
office (POS 11). 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 drug testing services (HCPCS 
G0480) provided to the enrollee on March 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided to the enrollee on July 17, 2019 and 
billed under code G0482. 
 
You asked the Plan to pay for code G0482. You say that this claim should be paid. The Plan denied your 
request. The Plan says while code 80307 was paid, the records provided do not support the billing of code 
G0482. The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type 
of testing. The physicians order and the medical records must specifically show how this testing will be used to 
treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for 
screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we 
decided that the Plan does not have to pay for drug testing provided to the enrollee on July 17, 2019 and billed 
under code G0482.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the outpatient surgical services rendered 
from January 29, 2020 to February 19, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that the services were performed in a 
separate building outside of the hospital that is not identified as an outpatient surgery center. The Plan denied 
your request. The Plan says the copayments were applied 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 a $250 
copayment for Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical 
center.  
 
Review of the file shows that you received outpatient surgical services on January 29, 2020 to January 31, 
2020. You have been asked to pay a $250 copayment for these services. These services fall within the 
Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical center benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.  
 
The file shows that you received outpatient surgical services for three dates of service from February 1, 2020 to 
February 19, 2020. You have been asked to pay a $250 copayment per date of service for these services, for a 
total of $750. These services fall within the Medicare-covered surgery or other services at an outpatient 
hospital or ambulatory surgical center 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 copayments for the outpatient surgical services rendered from 
January 29, 2020 to February 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care from April 3, 2020 
through April 8, 2020. 
 
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 due to the quality of care. The Plan denied your request. 
The Plan says the claim was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows that you were admitted on April 3, 2020 and discharged on April 8, 2020. You were 
asked to pay a $275 copayment per day from April 3, 2020 through April 7, 2020, days 1-5 of your inpatient 
hospital care. You were discharged on April 8, 2020 and there was no copayment charge for the day of 
discharge. Per your contract there is a $275 copayment per day required for days 1-6. 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 3, 2020 through April 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on 
August 14, 2019. 
 
You asked the Plan to waive the copayment for these services. You say that you have no received a bill. The 
Plan denied your request. The Plan says the copayment was applied 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 a $200 
copayment for each ambulatory surgical center visit.  
 
Review of the file shows that you received outpatient surgical services at an ambulatory surgical center on 
August 14, 2019. You have been asked to pay a $200 copayment for these services. These services fall within 
the each ambulatory surgical center visit 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 the outpatient surgical services rendered on August 14, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your records show you do not have a need for daily skilled services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $45 copayment for telehealth specialist services provided 
on May 14, 2020.   
 
You asked the Plan to waive the $45 copayment for telehealth specialist services provided on May 14, 2020.  
You say that you were unhappy with the telehealth services and feel you should not have to pay the copayment. 
The Plan denied your request. The Plan says this copayment is a contractual copayment. 
 
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 $45 
copayment for specialist telehealth 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 $45 copayment for telehealth specialist 
services provided on May 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you were medically stable with no evidence of need for supervision by an acute 
physical, medicine, and rehabilitation (PMR) physician or acute rehab nursing care. You may benefit from 
further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services 
rendered from August 7, 2019 to August 30, 2019. 
 
You asked the Plan to waive the copayment for these services. You say that you did not know the copayment 
would not be zero beyond 20 days. The Plan denied your request. The Plan says the copayment was applied 
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 a $0 
copayment per day for days 1-20 and a $125 copayment per day for days 21-100 for SNF care.  
 
Review of the file shows that the enrollee received 23 days of SNF care from August 7, 2019 to August 30, 
2019. The enrollee was not assessed a copayment for the date of discharge on August 30, 2019. The enrollee 
has been asked to pay a $0 copayment per day for days 1-20 and a $125 copayment per day for days 21-23 for 
these services, for a total of $375. These services fall within the SNF care benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay when they enrolled in the Plan. Therefore, we decided that the 
Plan does not have to waive the copayment for the skilled nursing facility (SNF) services rendered from August 
7, 2019 to August 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection into the finger (20550) 
performed on April 29, 2020. 
 
You asked the Plan to waive the copayment for an injection into the finger. You say that you received an 
injection, not outpatient surgery. The Plan denied your request. The Plan says the correct copayment was 
applied. 
 
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 $200 
copayment for Medicare-covered outpatient hospital surgery services.  
 
You have been asked to pay a $200 copayment for an injection into the finger. An injection into the finger 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 an injection into the 
finger (20550) performed on April 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided the Plan does not have to pay for out of network physician services provided on February 27, 2019.  
 
You asked the Plan to pay for these services. You say that the Plan should cover these services. The Plan 
denied your request. The Plan says the provider is billing for these services with inappropriate codes. The 
provider has been informed that a corrected claim is required. 
 
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 submitted by the out of 
network provided cannot be paid as billed. Until the claim is corrected, the Plan cannot pay these services. 
Therefore, we decided that the Plan does not have to pay for out of network physician services provided on 
February 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mammography provided on May 10, 2019. 
 
You asked the Plan to pay for the mammography. The Plan denied your request. The Plan says prior-
authorization is required for such services, which are obtained by an out of network provider. 
 
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 a mammography provided on May 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient level of care. 
 
You asked the Plan to pre-approve inpatient level of care. You say that the requested inpatient level of care is 
medically necessary. The Plan denied your request. The Plan says the requested inpatient level of care 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 inpatient level of care. Our reviewer 
says that the requested inpatient level of care is not medically necessary. Our physician reviewer found the 
enrollee in this case is with a diagnosed stage IV right ischial pressure wound. He was admitted for inpatient 
services to undergo debridement of the wound and to apply a wound VAC. The enrollee also has hypertension 
and is paraplegic. The plan afterward was to close the wound with local tissue about 3-5 days later. The notes 
do not describe an active condition which would warrant close observation and treatment in an inpatient 
setting. Observation status appears to be most appropriate in this situation, according to the provided notes. 
Therefore, the admission to inpatient level of care will be considered not medically 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 inpatient level of care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient level of care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 28 additional occupational therapy visits. 
 
You asked the Plan to pre-approve 28 additional occupational therapy visits. You say that these visits are 
medically necessary. The Plan denied your request. The Plan says the enrollee can transition to a home exercise 
program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 28 additional occupational therapy 
visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the requested therapy visits are not 
generally accepted or specific and effective therapy for the patient's condition generalized weakness. The 
records do not demonstrate that the unique skills of a professional therapist are required to safely and 
effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or 
for physical therapy and occupational therapy, by or under the supervision of a therapist. The care and 
assistance needed can be provided by aide services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 28 additional occupational therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 28 additional occupational therapy visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided from December 31, 
2019 through January 11, 2020 and January 16, 2020 through January 29, 2020. 
 
You asked the Plan to pay for SNF care. You say that this should be covered by Medicare. The Plan denied 
your request. The Plan says this was custodial care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care.. Our reviewer says that daily 
skilled services were not necessary. Our physician reviewer found from a nursing perspective, the beneficiary 
received oral medications and a course of IV antibiotics. The beneficiary had stable vital signs. His lungs were 
clear. He had routine foley catheter care. Regarding rehabilitation services, the beneficiary did not receive nor 
require any skilled services for the dates in question. The enrollee did not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care. have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility care provided from December 31, 2019 through January 11, 2020 and January 
16, 2020 through January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an immunotherapy service provided on 
February 12, 2020. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you did not have copayments for 
this service in the previous year. The Plan denied your request. The Plan says the copayment amount 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 $20 
copayment for specialist visit.  
 
You have been asked to pay the allowed amount of $10.36, which is less than the $20 copayment for specialist 
visit. Specialist 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 immunotherapy service provided on 
February 12, 2020.