Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital facility visit provided 
on June 18, 2020. 
 
You asked the Plan to waive the copayment for an outpatient hospital facility visit. You say that you disagree 
with the charges because the service you received is not considered an emergency. 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, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay $65, which is less than the $325 copayment for an outpatient hospital facility visit. 
An outpatient hospital facility visit 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 outpatient hospital facility visit provided on June 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on March 24, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT 
code 81479 for date of service March 24, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for Guardant360 testing provided on March 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion/specialty drug administration services 
coded 99601 and 99602 provided on March 12, 2020. 
 
You asked the Plan to pay for the home infusion/specialty drug administration services. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 
are not payable. 
 
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 99601 and 99602 are not supported in the medical record. Specifically, these codes 
have a status code of "I". A status code of I means that these services are not valid for Medicare purposes. 
Medicare uses another code for reporting of, and payment of these services. Based on this information, we 
decided that Medicare rules for coverage of the home infusion/specialty drug administration services have not 
been met. Therefore, we decided that the Plan does not have to pay for the home infusion/specialty drug 
administration services coded 99601 and 99602 provided on March 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated abutments and abutment supported crowns 
provided on May 6, 2020. 
 
You asked the Plan to pay for the prefabricated abutments and abutment supported crowns. You say that you 
were never informed that the dental plan changed in 2020. You say that you wouldn't have had the procedures 
if you knew they weren't covered. The Plan denied your request. The Plan says the services are not covered 
benefits. 
 
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 
prefabricated abutments and abutment supported crowns provided on May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the facet joint injections and lateral sacral nerve blocks 
provided on October 25, 2019. 
 
You asked the Plan to pay for the back injections. You say that the records support the necessity of this 
procedure. The Plan denied your request. The Plan says there is not sufficient documentation of conservative 
therapy. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections may be covered when the above 
criteria are met.  
 
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 back injections. Our reviewer says that 
the criteria for these injections have not been met and they are not considered medically necessary. Our 
physician reviewer found in this case, there is documentation of radiculopathy. The review has determined that 
the enrollee does not have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage 
 
 
of the facet injection services. It is not medically necessary or reasonable for this enrollee to have the facet 
injection services as requested. The review has determined that based on the rules and records provided, the 
requested facet injections are not medically reasonable or necessary for the enrollee's condition. 
 
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 back injections have not been met. Therefore, we decided that the Plan does 
not have to pay for the facet joint injections and lateral sacral nerve blocks provided on October 25, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 20, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you told the medics you had a negative 
experience at the hospital near you and they would not transport you to the hospital of your choice. The Plan 
denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 20, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridement services (11721)  provided December 
16, 2019. 
 
You asked the Plan to pay for the podiatry services. You say that the denial states that the provider needs to 
submit the claim however the provider has switched billing services and the old and new biller's are unable to 
submit because of this change over. The Plan denied your request. The Plan says this service is not covered by 
the plan benefits. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered.  However, the plan 
offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
The plan covers a maximum of 6 routine podiatry visits per plan year. We looked at your request, the records in 
the case file and the rules. Based on this information, we decided that you have exhausted the Plan maximum 
benefit for coverage for podiatry services. Therefore, we decided that the Plan does not have to pay for the nail 
debridement services (11721) provided December 16, 2019
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the injections and chemotherapy infusion provided on May 
14, 2020. 
 
You asked the Plan to pay for the injections and chemotherapy infusion. You say that the enrollee was only in 
hospice until May 1, 2020. You say that the claim should be reprocessed. The Plan denied your request. The 
Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 1, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the injections and 
chemotherapy infusion provided on May 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit (99213) provided on April 13, 2020 by an out of network (OON) provider.You asked the Plan to pay foroffice visit. You say that the beneficiary was unable to obtain a referral from their primary care physician.The Plandenied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plansays 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 forthe office visit (99213) provided on April 13, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by a 
participating facility on January 24, 2020. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you do not agree with 
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 $225 
copayment for outpatient hospital services/outpatient procedure.  
 
You have been asked to pay $117.74 which is less than your copayment amount of $225 copayment for 
outpatient hospital services. Outpatient hospital services fall within the outpatient hospital services/outpatient 
procedure benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient hospital services 
provided by a participating provider on January 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 22, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for laboratory tests. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-
network with the Plan and the referring provider is also out-of-network with 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 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 May 22, 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 home health services provided on May 19, 2020. 
 
You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 home health services provided on May 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic image provided on May 12, 
2020. 
 
You asked the Plan to pay for the 2D oral/facial photographic image. The Plan denied your request. The Plan 
says this service is not covered. 
 
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 2D 
oral/facial photographic image provided on May 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on February 5, 2020, to July 5, 2020.You asked the Plan to waive the coinsurance for durable medical equipment. You say that you do not agree with this coinsurance. The Plan denied your request. The Plan saysthe correct coinsurance 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 20% coinsurance for durable medical equipment. You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The total allowed amount is $353.30. The total amount you are being asked to pay is $70.66 ($353.30 x 20% = $70.66). Durable medical equipment falls within the durable medical equipment 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 durable medical equipment provided by a participating provider on February 5, 2020, to July 5, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing provided on June 3, 2020. 
 
You asked the Plan to pay for drug tests. You say that you are appealing with supporting documentation. The 
Plan denied your request. The Plan says that the denial of payment for these services is correct, because this 
provider is out-of-network with the Plan. 
 
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment is correct or 
justified according to Medicare rules. Therefore, we decided that the Plan has to pay for drug testing provided 
on June 3, 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 pay for the electrocardiogram services coded 93010 provided on 
April 21, 2020. 
 
You asked the Plan to pay for the electrocardiogram services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 93010 is electrocardiogram, routine ECG with at least 12 
leads; interpretation and report only. 
 
We find that CPT code 93010 is not supported in the medical record. Specifically, this service was billed on the 
same date of service as an emergency room visit. In addition, the documentation submitted appear to be 
incomplete or there was an error in transmission. Based on this information, we decided that Medicare rules for 
coverage of the electrocardiogram services have not been met. Therefore, we decided that the Plan does not 
have to pay for the electrocardiogram services coded 93010 provided on April 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office outpatient visit (99213) provided on April 15, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that referral and authorization requirements had been 
suspended for all in-network providers as a result of COVID-19. The Plan denied your request. The Plan says 
prior authorization must be obtained for non-emergent services rendered 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 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. The COVID-19 regulations regarding prior authorization applied to COVID-19 related 
diagnosis only. Otherwise, out-of-network providers were required to follow referral requirements and submit 
prior authorization requests. 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 office outpatient visit (99213) provided on 
April 15, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care (99308) provided on February 5, 
2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered 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 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 nursing facility care (99308) provided on 
February 5, 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 the brief communication technology-based service (G2012) 
provided on March 31, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for brief communication technology-based service. You say that the services 
rendered were medically necessary. The Plan denied your request. The Plan says prior authorization must be 
obtained for non-emergent services rendered 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 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 brief communication technology-based service 
(G2012) provided on March 31, 2020 by an out of network (OON) provider.