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

 
We decided that the Plan does not have to pay for home infusion therapy (S9500) provided on February 16, 
2020 through February 23, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT code S9500 has a status code of I 
which is not valid for Medicare purposes. 
 
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 code S9500 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9500 has a status code of I. This means that CPT code S9500 is not valid for Medicare purposes. Based 
on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been 
met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9500) provided on 
February 16, 2020 through February 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotic items provided on February 5, 2020. 
 
You asked the Plan to pay for orthotic items. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of payment for these items is correct, because the documentation 
submitted does not include valid proof of delivery for the specific items billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient 
information to determine whether payment is due for a claim. The information submitted by the provider must 
corroborate the medical documentation and confirm that Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. The documentation submitted does not include valid proof of 
delivery of the specific items billed on this claim. Namely, the proof of delivery submitted does not specifically 
indicate that the orthotic items billed on this claim were included in the delivery. The attached delivery ticket 
includes a shipping reference number but does not include proof of delivery to the beneficiary. The Plan 
requested supporting information, but this information was not provided. Without this information, you have 
not furnished sufficient information to the Plan to justify payment of the claim as it has been billed. Based on 
this information, we decided that Medicare rules for coverage of orthotic items have not been met. Therefore, 
we decided that the Plan does not have to pay for orthotic items provided on February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CPAP supplies provided on February 26, 2020. 
 
You asked the Plan to pay for the CPAP supplies. You say that you have sent an updated W-9. The Plan denied 
your request. The Plan says the Tax ID number is incorrect and they haven't received a corrected claim. 
 
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 claim submitted is unprocessable and a new claim has not been submitted. Based on this 
information, we decided that Medicare rules for coverage of the CPAP supplies have not been met. Therefore, 
we decided that the Plan does not have to pay for the CPAP supplies provided on February 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 14, 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, these services should 
be coded with code 81479. In addition, the appropriate DEX Z identifier should be entered adjacent to the code 
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 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the osseous surgery provided on February 11, 2020. 
 
You asked the Plan to pay more for the osseous surgery. You say that you were informed up to 50% was able 
to be covered. You say that you have not been provided the insurance you deserve. The Plan denied your 
request. The Plan says the claim processed correctly. 
 
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 Plan is only obligated to pay 50% 
of the allowed amount for your covered dental services from an out-of-network provider. The allowed amount 
is $282 ($282 - $100 deductible = $182).  
 
Billed Amount Allowed 
Amount 
Difference of 
Billed & Allowed 
Amount 
Deductible 50% 
Coinsurance 
Member 
Liability 
$1,450 $182 $1,168 $100 $91 $1,359 
 
Therefore, we decided that the Plan does not have to pay more for the osseous surgery provided on February 
11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 17, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the rest home visit (99336). You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says prior authorization is required but was 
not obtained by the provider or facility. 
 
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 the medical services provided on March 17, 2020 
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on March 11, 2020 to March 17, 2020 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford this 
copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $395 
copayment per day for days 1-4. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $395 copayment per day for days 1-4. There is a $0 copayment for additional 
days for an inpatient hospital stay. The total amount you are being asked to pay is $1,580 ($395 x 4 days = 
$1,580). 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 copayment for an inpatient hospital stay provided by a participating provider on 
March 11, 2020 to March 17, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient services provided from February 
3, 2020 to February 6, 2020. 
 
You asked the Plan to waive the copayment for the inpatient services. You say that the hospital made a mistake 
and asked you to come back in so you should not have to pay the copayment. The Plan denied your request. 
The Plan says you have been charged this copayment 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 $225 
copayment per days 1-7 for Inpatient Hospital Care.  
 
You have been asked to pay a $225 copayment, per days 1-2, for the inpatient services. The inpatient services 
fall 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 
inpatient services provided from February 3, 2020 to February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the physician services provided on April 15, 2020. 
 
You asked the Plan to reimburse you for the physician services. You say that the Plan should pay this claim. 
The Plan denied your request. The Plan says they cannot pay a provider who is not eligible to participate in 
Medicare. 
 
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 never accepted Medicare insurance. Therefore, we decided that the Plan does not have to 
reimburse you for the physician services provided on April 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 9, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for the medical services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the services were non-urgent and prior authorization was not requested. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the medical services provided on June 9, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 12, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on December 12, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
January 11, 2019. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you thought the 
ambulance services were covered. The Plan denied your request. The Plan says you were charged this cost 
sharing 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 each ambulance trip. You had one ambulance trip. The Plan charged you $250 for these 
services. 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 ambulance services provided on January 11, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from December 9, 2019 to 
December 30, 2019. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says prior 
authorization was not obtained by the 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 
psychotherapy 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 psychotherapy services provided from December 
9, 2019 to December 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided 
from January 15, 2019 through January 19, 2019. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. The Plan denied your request. 
The Plan says that the copayment 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 $225 
copayment for each day for days 1 to 4 for Medicare-covered hospital care.  
 
You have been asked to pay a $900 copayment for the inpatient hospital services. The inpatient hospital 
services fall within the days 1 to 4 for Medicare-covered 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 the inpatient hospital services provided from January 15, 2019 
through January 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on January 31, 
2020. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 
prior authorization was not obtained by the provider or facility. 
 
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 domiciliary or rest home visit provided on January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an auditory osseointegrated device (L8691) provided on 
November 6, 2019. 
 
You asked the Plan to pay for an auditory osseointegrated device. You say that this is an implantable device 
that offered medically necessary features. The Plan denied your request. The Plan says the documentation is 
not sufficient to verify indications for these implants. 
 
The Plan must follow Medicare rules. Medicare rules say that while osseointegrated implants are payable by 
Medicare as prosthetic devices, they are indicated only when hearing aids are medically inappropriate or cannot 
be utilized due to congenital malformations, chronic disease, severe sensorineural hearing loss or surgery. The 
rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. No medical records have been submitted to show whether the device 
at issue is indicated for the enrollee in this case. Based on this information, we decided that Medicare rules for 
coverage of an auditory osseointegrated device have not been met. Therefore, we decided that the Plan does not 
have to pay for an auditory osseointegrated device (L8691) provided on November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot orthosis coded L1971 provided on March 27, 
2020. 
 
You asked the Plan to pay for the ankle foot orthosis. 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 documetnation. 
 
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 L1971 is ankle foot orthosis, plastic or other material 
with ankle joint, prefabricated, includes fitting and adjustment. 
 
We find that CPT code L1971 is not supported in the medical record. Specifically, the medical records indicate 
that ankle foot orthosis, multiligamentous ankle support, prefabricated, off-the-shelf was ordered. There is a 
more appropriate Healthcare Common Procedure Coding System (HCPCS) code that should be used instead. 
Based on this information, we decided that Medicare rules for coverage of the ankle foot orthosis have not been 
met. Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis coded L1971 provided 
on March 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home ventilator provided on April 16, 2020. 
 
You asked the Plan to pay for the home ventilator. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the item billed is not supported by the documentation. 
 
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 physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The submitted order does not include a 
completed physician's order, including the length of need of the item. 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 home ventilator provided on April 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for podiatry services provided on January 14, 
2020 and January 21, 2020. 
 
You asked the Plan to waive the deductible for the podiatry services. You say that your membership card 
indicates that your copays are $0 and that you should not have to pay any of the bills. 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).  
 
On January 14, 2020, you received podiatry service code:  11042  Debridement, subcutaneous tissue 
(includes epidermis and dermis, if performed). The Medicare-allowed amount for service code 11042 is 
$125.25. At the time of claim processing, you had not met any of your $159 2020 deductible; therefore, the 
entire Medicare-allowed amount of $125.25 was applied to your 2020 deductible. 
 
On January 21, 2020, you received podiatry service codes: 99214  Office or other outpatient visit for the 
evaluation and management of an established patient. 73610RT Radiologic examination, ankle; complete, 
minimum of 3 views. 73630RT Radiologic examination, foot; complete, minimum of 3 views. 15271 
Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm. The overall 
Medicare-allowed amount for procedure codes 99214, 73610, 73630 and 15271 is $306.87.At the time of claim 
processing, you had only met $125.25 of their $150 2020 deductible; therefore, $24.75 of the $306.87 
Medicare-allowed amount was applied to your $150 2020 deductible. 
 
Your EOC states, "Your combined in-network and out-of-network medical deductible is $150. This is the 
amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until 
you have paid the deductible amount, you must pay the full cost for most of your covered services. (The 
deductible does not apply to the services that are listed below.) Once you have paid your deductible, we will 
begin to pay our share of the costs for covered medical services and you will pay your share (your copayment 
or coinsurance amount) for the rest of the plan year." 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 deductible for 
podiatry services provided on January 14, 2020 and January 21, 2020.