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

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on June 3, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says code G0483 remains not supported. The place of service on the CMS-1500 form line 
24B must reflect the location of the patient when the specimen was obtained. The submitted claim form 
indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical 
documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.  Also, 
the laboratory results submitted indicate the specimen was collected on June 3, 2020 and received by the lab on 
June 4, 2020. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the claim submitted cannot be paid as 
billed due to an issue with the POS code. Medicare rules for coverage of this service have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on June 3, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4190), periodic oral evaluation - 
established patient (D0120) and unspecified preventive procedure, by report (D1999) provided on July 6, 2020. 
 
You asked the Plan to pay for periodontal maintenance, periodic oral evaluation - established patient and 
unspecified preventive procedure, by report. You say that the services were medically necessary. The Plan 
denied your request. The Plan says your Plan has no out-of-network coverage, and the provider is not in 
network with the Plan. 
 
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. Specifically, you went to a provider out-of-network. You Plan does not 
allow you to utilize out-of-network providers. Therefore, we decided that the Plan does not have to pay for 
periodontal maintenance (D4190), periodic oral evaluation - established patient (D0120) and unspecified 
preventive procedure, by report (D1999) provided on July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Gel-One injection provided on July 24, 
2020. 
 
You asked the Plan to waive the coinsurance for the Gel-One injection. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received a Part B injection on the date of service at issue in this appeal. The 
Plan says that the correct coinsurance has applied per your contract with the Plan. 
 
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.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a Gel-One 
injection on July 24, 2020. You have been asked to pay a 20% coinsurance for the Gel-One injection, totaling 
$438.24. The Gel-One 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 the Gel-One injection provided on July 24, 2020.  
 
 
 
 
 
 
 
Your complaint about the possibility of having a reaction to the injection is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on June 12, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that because of Covid-19 
you had to go to the emergency room. You say normally this would only cost you $5. 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 $90 
copayment for emergency room visit.  
 
You have been asked to pay a $90 copayment for an emergency room visit. Since an emergency room visit 
occurred, the correct copayment has been applied. An emergency room visit falls within the emergency room 
visit benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit 
provided by a participating provider on June 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you $150 for the OTC items provided from January 1, 2020, through  
October 5, 2020. 
 
You asked the Plan to reimburse you $150 for the OTC items. You say that you were unaware of the OTC benefit and 
you believe that you should be allowed to order an additional $150 worth of items for the benefits that you did not 
receive. The Plan denied your request. The Plan says you are eligible for a $50 quarterly benefit to be used toward the 
purchase of OTC health and wellness products available through the Plan's mail order service. One order is allowed in 
each three month-period. The unused balance does not carry over to the next three months. 
 
The Plan contract says that you are eligible for a $50 quarterly benefit to be used toward the purchase of OTC health and 
wellness products available through the Plan's mail order service. One order is allowed in each three month-period. The 
unused balance does not carry over to the next three months. 
 
We looked at the file and the Plan's rules. The file shows that the Plan's supplemental OTC benefit covers a $50 
quarterly benefit to be used toward the purchase of OTC health and wellness products available through the Plan's mail 
order service. One order is allowed in each three month-period. The unused balance does not carry over to the next three 
months. Therefore, we decided that the Plan does not have to reimburse you $150 for OTC items provided from January 
1, 2020, through October 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
May 28, 2020 to June 4, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you feel you should not 
be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received inpatient hospital care on the dates of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $335 
copayment per day for days 1-5 for Inpatient hospital care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received inpatient 
hospital care from May 28, 2020 to June 4, 2020. You have been asked to pay a $335 copayment per day for 
days 1-5 for the inpatient hospital care, totaling $1675. The inpatient hospital care 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 the inpatient hospital care 
provided from May 28, 2020 to June 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says you could receive care in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple 
therapies such as physical and occupational therapy, but the documentation does not support that your 
functional status requires or can tolerate an intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 01630 provided on May 30, 
2020. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 01630 is anesthesia for open or surgical arthroscopic 
procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; not 
otherwise specified. 
 
We find that CPT code 01630 is not supported in the medical record. Specifically, this code was billed with a 
primary diagnosis of S42.301S (Unspecified fracture of shaft of humerus, right arm, sequela). This code is 
identified as a secondary only diagnosis. Secondary diagnosis codes cannot be billed as the primary, first -listed 
or principal diagnosis for any procedure or service. Based on this information, we decided that Medicare rules 
for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to 
pay for the anesthesia services coded 01630 provided on May 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (43239) 
provided on August 26, 2020. 
 
You asked the Plan to waive the copayment for an esophagogastroduodenoscopy. You say that this charge is 
excessive. The Plan denied your request. The Plan says this processed 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 $395 
copayment for outpatient surgery.  
 
You have been asked to pay a $395 copayment for an esophagogastroduodenoscopy, which falls within the 
outpatient surgery 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 
esophagogastroduodenoscopy (43239) provided on August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services billed to the enrollee for May 8, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the records show this procedure was not completed due to discomfort from local 
anesthesia. The Plan states that Medicare only pays for services which are actually rendered. 
 
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, this claim cannot be paid as billed 
as the services were not rendered. Medicare rules for coverage of this service have not been met. Therefore, we 
decided that the Plan does not have to pay for physician services billed to the enrollee for May 8, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
December 27, 2019. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you feel you should 
not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received emergency room services on the date of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $110 
copayment for Emergency care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room 
services on December 27, 2019. You have been asked to pay a $110 copayment for the emergency room 
services. The emergency room services fall within the Emergency 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 emergency room services provided on December 27, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from April 27, 2020 to April 
29, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital care provided 
from April 27, 2020 to April 29, 2020 was medically necessary. The Plan denied your request. The Plan says 
that the inpatient hospital care provided from April 27, 2020 to April 29, 2020 was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the inpatient hospital care provided from April 27, 2020 to April 29, 2020 was medically necessary. 
Our physician reviewer found the review indicates that the enrollee presented to the emergency room on 
4/27/2020 with increased leg swelling. On evaluation BP was 153/56 and the physical exam demonstrated +4 
edema of the lower extremities with erythema. Labs revealed a WBC 7.1, creatinine 0.80, troponin 0.062 and 
BNP 1380. The EKG was without any acute ischemic changes and the chest x-ray demonstrated mild congest 
heart failure (CHF). Ultrasound of the lower extremities were negative for DVT. She was treated with 
supplemental O2, IV Lasix and IV antibiotics (Levaquin and Rocephin). She was admitted and her condition 
stabilized and improved with medical therapy. She was discharged home on 4/29/2020 with outpatient follow-
up. 
 
The review has determined that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from April 27, 2020 to April 29, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided. 
 
You asked the Plan to pay for home health services. You say that these services were necessary. The Plan 
denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the services at issue were provided by a 
provider that appears to not be certified for Medicare. The provider at issue did not come up on the 
Medicare.gov search for Home Health providers serving your area. There was no documentation supplied by 
the provider to verify that they are certified by Medicare. Therefore, we decided that the Plan does not have to 
pay for home health services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on October 22, 2019, by an 
out-of-network provider. 
 
You asked the Plan to pay for the physician services. You say that the doctor is not responsible for getting 
authorization. The Plan denied your request. The Plan says you did not request 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 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 physician services provided on October 22, 2019, by an out-of-network 
provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram reporting (93010) provided on  
April 12, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for 
payment. The Plan denied your request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, 
covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first 
day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. 
Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill 
Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided 
that the Plan does not have to pay for the electrocardiogram reporting (93010) provided on  
April 12, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan of the whole body (78816).You asked the Plan to pre-approvea PET CT scan of the whole body. You say that the services are necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 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 a PET CT scan of the whole body. Our reviewer says that the services are medically necessary. Our physician reviewer found the requested PET/CT is important to determine if there is increased metabolic activity within bone todetermine if re biopsy is indicated.  This alone qualifies for PET/CT per NCD guidelines. In addition, it should be noted that conventional imaging including bone scan, CT and plain films may be negative in cases of myeloma. As such PET/CT is the most sensitive imaging means for evaluating you. In addition the prior PET/CT of 2019 will serve as an important baseline.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET CT scan of the whole body have been met.Therefore, we decided that the Plan has to pre-approvea positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan of the whole body (78816).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.