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

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on June 4, 2020, and June 16, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you had to wait to get this 
procedure due to the pandemic and because of this you don't feel like you should have to pay. The Plan denied 
your request. The Plan says the correct copayments have 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 $600 
copayment for outpatient surgery/in-network.  
 
You have been asked to pay a $600 copayment for each outpatient surgery. The total amount you are being 
asked to pay is $1,200 ($600 x 2 surgeries = $1,200). An outpatient surgery falls within the outpatient 
surgery/in-network 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 surgery 
provided by a participating provider on June 4, 2020, and June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from January 3, 2020, to 
January 22, 2020. 
 
You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that only certain types of bill may be used for home 
health services.  
 
We looked at the file and Medicare rules. The home health services in question were billed with type of bill 
321. This is not a valid type of bill for home health services. Based on this information, we decided that 
Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from January 3, 2020, to January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye and medical examination for diagnosis and treatment 
(92014) provided on January 15, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the eye and medical examination for diagnosis and treatment. You say that the 
exam was strictly medical, and assessed the health of the eye, rather than the testing the patient's vision. The 
Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider; 
therefore, payment has been correctly denied. 
 
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 eye and medical examination for diagnosis and 
treatment (92014) provided on January 15, 2020, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on June 23, 2020 by the out of network provider.You asked the Plan to pay forthe dental services. You say that you have been seeing this provider for 23 years. You say that you would like these services to be covered as you do not trust another dentist at this point.The Plan denied your request. The Plan says the provider in this case is not a participating provider. The Plan also says that services will only be covered when you receive them from a participating provider.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 and the services you received are listed as covered, they are not covered when you receive the services out of network.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on June 23, 2020 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on January 17, 2019 and 
billed under codes 80307 and G0482. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says Current Procedural Terminology (CPT) codes 80307 and G0482 remains 
not supported. The documentation submitted did not include a valid physician order/lab requisition or medical 
records (signed by the ordering physician) for the billed test; therefore, the billed test cannot be verified. It is 
noted multiple attempts were made to obtain additional information from the provider. 
 
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 lab services provided to the enrollee on January 17, 2019 and 
billed under codes 80307 and G0482.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission is not medically necessary. 
 
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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the submitted records show that you 
were admitted to the hospital on October 4, 2020 for shortness of breath, irregular heartbeat (atrial fibrillation), 
and pneumonia. You had stable vital signs and were treated for pneumonia. You received physical and 
occupational therapy in the hospital and are able to walk 200 feet with a rolling walker and assistance. You 
need varied assistance with activities of daily living. You have no skilled nursing needs. You have skilled 
therapy needs but do not require skilled therapy on a daily basis. As a practical matter, you do not require the 
necessary services on an inpatient basis at the SNF level of care. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on February 10, 2020.You asked the Plan to pay forthe assemblyand operation of a pump with an oxygenator or heat exchanger. You say that this was a necessary service.The Plan denied your request. The Plan says payment for this service is included in the DRG. The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on June 24, 2020. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you already paid a $20 copayment. 
You say that you should not owe this additional amount. The Plan denied your request. The Plan says the 
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 Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $237.50. The total amount you are being asked to pay is $47.50 ($237.48 x 20% = $47.50). An 
injection falls within the Medicare Part B prescription drugs benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for an injection provided by a participating provider on June 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on June 7, 2020 billed with 
codes 83036, 80061, and 84460. 
 
You asked the Plan to pay for the lab testing. You say that these were billed correctly and should be paid. The 
Plan denied your request. The Plan says this lab has a CLIA waiver certificate but the lab codes were not billed 
with the -QW modifier as required. 
 
The Plan must follow Medicare rules. Medicare rules say that labs which only performed CLIA-waived tests 
are allowed to be reimbursed for these tests if they have a CLIA waiver and the tests are billed using the correct 
code with a -QW modifier. 
 
In this case, these codes are payable to CLIA-waived laboratories only when billed with -QW which was not 
included on the claim. As such, the billing rules for these services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory testing provided on June 7, 2020 billed with codes 83036, 
80061, and 84460.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 88323) provided on April 17, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code has an MUE 
value of 1. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 88323 is 1. You billed 6 units of this code, exceeding the MUE. 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 the services (CPT 88323) provided on April 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, and emergency 
transport (A0429) and ambulance response and treatment, no transport (A0998). 
 
You asked the Plan to pay for ambulance services. You say that you feel the services should be covered. The 
Plan denied your request. The Plan says the provider did not bill the claims correctly 
 
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 A0998 and A0429 is ambulance service, basic life 
support, emergency transport (A0429) and ambulance response and treatment, no transport (A0998). 
 
We find that CPT code A0998 and A0429 is not supported in the medical record. Specifically, Medicare rules 
state that when an enrollee is pronounced dead after the ambulance is called but before the ambulance arrives, 
code A0428 should be used. Based on this information, we decided that Medicare rules for coverage of 
ambulance service, basic life support, and emergency transport (A0429) and ambulance response and 
treatment, no transport (A0998) have not been met. Therefore, we decided that the Plan does not have to pay 
for ambulance service, basic life support, and emergency transport (A0429) and ambulance response and 
treatment, no transport (A0998).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99214) 
provided on March 3, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. 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 by the facility or the provider; therefore, payment has been correctly denied. 
 
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 established patient office or other outpatient 
visit (99214) provided on March 3, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller with harness upgrade and 
electronic connection for a power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that an expandable controller with harness and electronic 
connection are allowed when necessary when three power options are provided.  
 
We looked at the file and Medicare rules. The file does not support that the requested expandable controller 
with harness and electronic connection are necessary for the enrollee. 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 pre-approve an expandable controller with harness upgrade and electronic connection for a power 
wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialists office visit and Medicare 
Part B injection services provided December 4, 2019, December 11, 2019, and December 30, 2019. 
 
You asked the Plan to waive the copayment for the office visit and injection services. You say that you have 
enclosed the receipt showing your payment of $400 needed to meet your max and the subsequent $767.82 
overpayment of your policy which is owed back to you. Please reimburse for the overpayment. The Plan denied 
your request. The Plan says the plan reprocessed the claim and waved the $20 copayment that applied in error 
for laboratory services and the remaining cost shares 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 20% 
coinsurance for Part B medications and $20 copay for Specialist services (including surgery second opinion 
and telehealth or urgently needed services).  
 
You have been asked to pay $1,127.82 for the office visit and injection services. The office visit and injection 
services fall within the Medicare Part B prescription drugs and 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 the specialists office 
visit and Medicare Part B injection services provided December 4, 2019, December 11, 2019, and December 
30, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital clinic services you 
received from March 4, 2020, through March 18, 2020. 
 
You asked the Plan to waive the copayment for the outpatient hospital clinic services. You say that this cost 
sharing is outrageous. The Plan denied your request. The Plan says you were charged these copayments 
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 $325 
copayment for non-surgical visits in an outpatient hospital clinic.  
 
You have been asked to pay a $325 copayment for the outpatient hospital clinic 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 outpatient hospital clinic services you received from March 4, 2020, 
through March 18, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
February 14, 2020. 
 
You asked the Plan to pay for home health services. 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. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, home health 
claims require the Treatment Authorization Code, Q code, HHRG code and correct Bill Type to process for 
payment. A treatment authorization code was not provided on the claim. Therefore, we decided that the Plan 
does not have to pay for the home health services provided to the enrollee from February 14, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from February 24, 
2020, to March 19, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare act. The Plan denied your request. The Plan says the enrollee 
required no nursing services which would be considered skilled services by Medicare. 
 
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 the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from February 24, 2020, to March 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing rendered on March 20, 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 the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing is covered when specific 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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a history of ovarian and 
skin cancer. Based on the provided records for this patient, there was no clear justification made for this 
request. Genetic testing in this case would not provide an important change in treatment for her current 
condition. There were no documented plans for a change in treatment based on the results. Therefore, the 
testing was 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the genetic testing rendered on March 20, 2020.