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

We decided that the Plan does not have to pay for physician services provided on January 17, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you were unaware that the member changed 
insurance policies. 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. 
 
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 physician services provided on January 17, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 30, 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 codes 80157,80177, 80201, 80162, 80159 and 80173 are 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. 
 
We find that CPT codes 80157,80177, 80201, 80162, 80159 and 80173 are not supported in the medical record. 
Specifically, there is no documentation that the testing was performed on blood specimens. 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 laboratory services rendered on March 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 22, 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 codes 80157, 80177, 80201, 80162, 80159 and 80173 are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159 and 80173 are not supported in the medical 
record. Specifically, there is no documentation of testing performed on blood specimens. 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 laboratory services rendered on April 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the X-ray of knee (73562) provided on 
June 15, 2020. 
 
You asked the Plan to waive the copayment for the X-ray of knee. You say that you are unaware why you 
needed an X-ray. The Plan denied your request. The Plan says the copayment applied correctly in this case. 
 
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 $50 
copayment for Medicare-covered X-rays and ultrasounds.  
 
You have been asked to pay a $50 copayment for the X-ray of knee. The service provided falls within the 
Medicare-covered X-rays and ultrasounds 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 X-ray of knee (73562) provided on June 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the vitreous procedures of the eye (code 
67028) you had from January 31, 2020, to March 20, 2020, at an outpatient hospital facility. 
 
You asked the Plan to waive the copayment for the vitreous procedures of the eye. You say that you should 
only have to pay 20% of the cost since these services included injections.  You said that this is a substantial 
financial burden for you. The Plan denied your request. The Plan says you were charged these copayments 
correctly.  The Plan says that because the allowed amount for each procedure is less than your copayment 
obligation, you are responsible for the full 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 $395 
copayment for surgical services at an outpatient hospital facility.  
 
You have been asked to pay a $395 copayment for the vitreous procedures of the eye. Medicare rules state that 
services coded as 67028 are considered surgical services.  That is why the vitreous procedures of the eye fall 
within the surgical services at an outpatient hospital facility 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 vitreous procedures of the eye (code 67028) you had from January 31, 2020, to 
March 20, 2020, at an outpatient hospital facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services provided on June 29, 2020. 
 
You asked the Plan to pay more for the dental services. You say that your teeth were badly infected requiring 
surgical removal. You say that the surgery should have been paid. The Plan denied your request. The Plan says 
your benefit has been exhausted. 
 
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, you also have an annual maximum of 
$1,000. The Plan finished paying $1,000 toward the dental services received on June 29, 2020, which 
exhausted your benefit. Therefore, we decided that the Plan does not have to pay more for the dental services 
provided on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued chiropractic care. 
 
You asked the Plan to pre-approve continued chiropractic care. You say that this care is medically necessary. 
The Plan denied your request. The Plan says once the 36 visits are exhausted, they are not extended. 
 
Medicare does not cover chiropractic maintenance care. The Plan covers 36 chiropractic visits per year. Once 
this benefit is exhausted, the Plan is not required to extend it. Therefore, we decided that the Plan does not have 
to pre-approve continued chiropractic care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk panel testing provided on December 29, 
2019. 
 
You asked the Plan to pay for screening testing. You say that you use the referring physician's order form as the 
sole basis for provided the requested tests. The Plan denied your request. The Plan says the denial of payment 
for these services is correct, because Medicare does not cover this cardiovascular risk assessment panel under 
the circumstances. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, screening testing, were requested for screening purposes. Medicare does not 
cover these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for 
cardiovascular risk panel testing provided on December 29, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $225 copayment charged for ambulance transport 
provided on April 9, 2020. 
 
You asked the Plan to waive this copayment. You say that you would like the Plan to reconsider the 
copayment. The Plan denied your request. The Plan says this copayment was charged based on the services 
provided and the Plan contract agreement. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $225 
copayment for ambulance transport. You have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the $225 copayment charged for ambulance 
transport provided on April 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe domiciliary or rest home visit for the evaluation and management of an established patient (99336) provided on June 12, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe domiciliary or rest home visit. You say that services not provided by PCM. Medical records attached.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.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, outof 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 domiciliary or rest home visit for the evaluation and management of an established patient (99336) provided on June 12, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete maxillary denture and a complete mandibular denture.You asked the Plan to pre-approvethe complete maxillary and mandibular dentures. You say that you need complete dentures because you recently received extractions that were holding your partial dentures.The Plan denied your request. The Plan says these services are allowed one time every 60 months. The Plan also says that you received these services less than 60 months ago.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, dentures are limited to one set every 5 years. The record shows that you received a complete maxillary denture and partial mandibular denture on June 4, 2019, and your dentures benefit has been exhausted.Therefore, we decided that the Plan does not have to pre-approvea complete maxillary denture and a complete mandibular denture.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nuclear stress test you had at an 
outpatient hospital facility on July 15, 2020. 
 
You asked the Plan to waive the copayment for the nuclear stress test. You say that you cannot afford this 
amount. The Plan denied your request. The Plan says you were 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 $275 
copayment for advanced imaging services (including nuclear medicine).  
 
You have been asked to pay a $275 copayment for the nuclear stress test. The nuclear stress test falls within the 
advanced imaging services (including nuclear medicine) 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 nuclear stress test you had at an outpatient hospital facility on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foranesthesia services (01638, 64415 and 76942) provided on November 20, 2020.You asked the Plan to pay forthe anesthesia services. You say that you would like reconsideration because this claim was denied in error.The Plan denied your request. The Plan says there is insufficient information to determine if criteria for coverage have been met.The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Specifically, the record does not include any clinical documentation. There is insufficient information to determine whether payment is due and the amount of payment.Therefore, we decided that the Plan does not have to pay foranesthesia services (01638, 64415 and(76942) provided on November 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on June 19, 2020 under code 
97140. 
 
You asked the Plan to pay for code 97140. You say that this claim should be paid. The Plan denied your 
request. The Plan says only those services that relate to manual manipulation of the spine are covered by the 
Plan or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services provided on June 19, 2020 under codes 98941 and 97140.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided on February 11, 2020 through February 
27, 2020. 
 
You asked the Plan to pay for the services. You say that you would like reconsideration because this is a 
covered service regardless of network status. The Plan denied your request. The Plan says revenue code 821 is 
required to be submitted with code 90999. 
 
The Plan must follow Medicare rules. Medicare rules say that all hemodialysis claims must include HCPCS 
90999 on the line reporting revenue code 082x. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, the record shows that revenue code 0821 was billed 
with CPT code 90935. Revenue code 082X must include code 90999. Therefore, we decided that the Plan does 
not have to pay for services provided on February 11, 2020 through February 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advanced life support (ALS) (A0433) and ground 
mileage (A0425) provided on June 16, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit by 
Medicare or your contractual policy. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area.  
 
The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we 
decided that the Plan does not have to pay for the advanced life support (ALS) (A0433) and ground mileage 
(A0425) provided on June 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chest x-ray you had at an outpatient 
hospital facility on July 7, 2020. 
 
You asked the Plan to waive the copayment for the chest x-ray. You say that you had a referral for this service.  
You said that the provider you used in the past didn't charge a copayment for chest x-rays. The Plan denied 
your request. The Plan says you were 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 $50 
copayment for x-rays in an outpatient hospital setting.  
 
You have been asked to pay a $50 copayment for the chest x-ray. 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 chest x-ray you had at an outpatient hospital facility on July 7, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for enteral nutrition therapy (A9342) provided on May 1, 2020, 
through May 31, 2020. 
 
You asked the Plan to pay for the enteral nutrition therapy. You say that you would like reconsideration 
because this service is medically necessary. The Plan denied your request. The Plan says procedure code S9342 
has a status indicator 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 S9342 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9342 has a status indicator of I. This means that CPT code S9342 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the enteral nutrition therapy have 
not been met. Therefore, we decided that the Plan does not have to pay for enteral nutrition therapy (A9342) 
provided on May 1, 2020, through May 31, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99350) provided on July 15, 2019. 
 
You asked the Plan to pay for the home visit. You say that you would like reconsideration because the services 
rendered were medically necessary. The Plan denied your request. The Plan says the billed code does not 
appropriately reflect the services provided by the certified nursing assistant. 
 
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 99350 is home visit for the evaluation and management 
of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval 
history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling 
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the 
presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a 
significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face 
with the patient and/or family.  
 
We find that CPT code 99350 is not supported in the record. Specifically, the record does not support that the 
physician was present in the beneficiary's home. Based on this information, we decided that Medicare rules for 
coverage of the home visit have not been met. Therefore, we decided that the Plan does not have to pay for the 
home visit (99350) provided on July 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted procedure, nervous system (64999) provided. 
 
You asked the Plan to pay for the unlisted procedure. You say that please review the attached information to 
support the use of this block for post-operative pain requested by the surgeon. The Plan denied your request. 
The Plan says resubmit the claim with the appropriate Asa code. 
 
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 64999 is other procedures of the nervous system. 
 
We find that the claim was submitted with an invalid or incorrect Asa code. The claim must be resubmitted 
with the appropriate Asa code. Based on this information, we decided that Medicare rules for coverage of the 
unlisted procedure have not been met. Therefore, we decided that the Plan does not have to pay for unlisted 
procedure, nervous system (64999) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fordurable medical equipment provided on June 11, 2020 by an out of network (OON) provider.You asked the Plan to pay fordurable medical equipment. You say that you could not find an in-network provider.The Plan denied your request. The Plan says prior authorization was not obtained.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 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 fordurable medical equipment provided on June 11, 2020 by an out of network (OON) provider.