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

We decided that the Plan does not have to pay for the creation of flap graft to head and/or neck (15733) 
provided on January 23, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the creation of flap graft to head and/or neck. You say that you believe that the 
medical documentation supports the medical necessity of procedure. 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 creation of flap graft to head and/or neck 
(15733) provided on January 23, 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 provided on April 10, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or 
hospital for services furnished to the beneficiary while an inpatient.  
 
We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during 
an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on April 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ER visit provided on March 25, 2020. 
 
You asked the Plan to pay for the ER visit. You say that the enrollee was discharged from hospice on March 
12, 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 March 12, 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 ER visit provided 
on March 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthoses (L2385, L2830) provided April 9, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the items were medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The provided delivery ticket was itemized. The delivery 
date does not match the date of service on the claim form submitted. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for the orthoses (L2385, L2830) provided April 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for home health services provided from August 2, 2019, to 
August 29, 2019. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the provider did not bill with an appropriate Q code on the claim.  
 
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 due 
to a Q code error. The Plan states a corrected claim would be reviewed if submitted. Therefore, we decided that 
the Plan does not have to pay for home health services provided to the enrollee from August 2, 2019, to August 
29, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on May 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 code 71045 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 71045 and 71046. Code 71045 is a column II code with a 
modifier indicator of 1 when billed with column I code 71046. Code 71045 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest 
x-ray rendered on May 30, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care provided on February 17, 2020. 
 
You asked the Plan to pay for subsequent hospital care. You say that you were taken off hospice and went to 
the hospital as soon as possible. You say that the situation was remedied after 2 days and you were placed back 
on hospice care. 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 February 16, 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 subsequent hospital 
care provided on February 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services you received on 
April 14, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the hospital told your 
family there would be no cost for this transport. 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 $285 
copayment for ambulance services.  
 
You have been asked to pay the full allowed amount of $268 for this ambulance service because the allowed 
amount is less than your copayment obligation. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance services you received on April 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (HIT) administrative services 
provided from January 24, 2020 to January 29, 2020. 
 
You asked the Plan to pay for the HIT services. You say that these services should be paid. The Plan denied 
your request. The Plan says this service is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code S9502 has a status indicator of "I" on the Physician Fee Schedule. This means that this code is 
invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage 
of the HIT services have not been met. Therefore, we decided that the Plan does not have to pay for the home 
infusion therapy (HIT) administrative services provided from January 24, 2020 to January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear provided on May 1, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for the OON eyewear. You say that you had to go to an OON provider because 
everything else was closed due to the pandemic. You believed that the Plan would make an exception in these 
circumstances. The Plan denied your request. The Plan says you are required to receive care from network 
providers. Non-urgent OON services must be pre-approved by the Plan. You did not contact the plan to receive 
approval to use this OON 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 eyewear provided on May 1, 2020 by an out of 
network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency department visit (99283). 
 
You asked the Plan to pay for the emergency department visit. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim was filed more 
than one calendar year from the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department visit was not filed with the appropriate Medicare 
contractor until January 23, 2020. This means that more than one calendar year from the date of service had 
passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the emergency 
department visit (99283)
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for 2 emergency room visits on November 9 
and November 10, 2019 or to pay for a self-administered drug received in the emergency room on November 9, 
2019. 
 
You asked the Plan to waive the copayments for 2 emergency room visits and to pay for a self-administered 
drug. You say that you should not have to pay because these emergency services never helped your broken 
arm. The Plan denied your request. The Plan says the correct copayments were applied. 
 
Regarding the request to waive the copayments for 2 emergency room visits: 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 each Medicare-
covered emergency room visit.  
 
You have been asked to pay a $90 copayment for each of 2 emergency room visits. Emergency room visits 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 copayments for 2 
emergency room visits on November 9 and November 10, 2019.  
 
Regarding the request to pay for a self-administered drug: the Plan must follow Medicare rules. The rules say 
that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested 
here is not among the types which are covered by Medicare Part B. 
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services (82947, 74330, 43264, J2704) 
provided on September 3, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you believe the medical record supports the 
services performed. 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 outpatient services (82947, 74330, 43264, 
J2704) provided on September 3, 2019, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral or facial photographic image (D0350 x 4) 
provided on June 9, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services you received were provided by an 
in network provider. The Plan denied your request. The Plan says 2D oral or facial photographic image is not 
listed as a covered service. 
 
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 or facial photographic image (D0350 x 4) provided on June 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), 
and sales tax (D9985) provided on January 23, 2020. 
 
You asked the Plan to pay for the dental services. You say that you had an information meeting with the Plan 
and they told them that the provider is out of network but the claim would still be paid. The Plan denied your 
request. The Plan says the provider was opted out of Medicare on the date of service. The Plan says payment 
cannot be made for services provided by a dentist who has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the periodic oral evaluation (D0120), prophylaxis (D1110), and sales tax (D9985) provided on January 23, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay on August 7 to 
August 17, 2017. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this copayment should 
be waived as remediation for the administrative challenge the lengthy appeal process has posed. The Plan 
denied your request. The Plan says the correct copayment was 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 each day of days 1-6 for each Medicare-covered stay.  
 
You have been asked to pay $1,350, or a $225 copayment for each day of days 1-6, for an inpatient hospital 
stay. An inpatient hospital stay falls within the "Inpatient hospital care" benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an inpatient hospital stay on August 7 to August 17, 2017.  
 
Your complaint about the administrative burden, due to extensive Plan and provider errors, that this lengthy 
appeal has placed on you 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on January 29, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on January 29, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department (ED) services rendered on 
October 25, 2019. 
 
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 code 99285 is 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. 
 
In this case, the CPT Code Manual definition of code 99285 is Level 5 emergency department visit for 
evaluation and management of patient with problem immediately threatening life, including comprehensive 
history and physical examination, and medical decision-making of high complexity. 
 
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 
procedure code 99285 is not supported. Our physician reviewer found billing CPT 99285 requires the 
documentation of a comprehensive history, comprehensive examination and medical decision making of high 
complexity.  Furthermore, the complaint is usually one of great severity, which poses an immediate risk to the 
health of the patient.  In this case, the enrollee was seen in the ED for not getting along with his mother.  The 
enrollee was well behaved in the ED and was not deemed to be a threat to himself or others.  Basic laboratory 
testing was performed, and the enrollee was discharged to follow up with his PCP.  As such, the billing of CPT 
99285 is not supported. 
 
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 emergency department (ED) services rendered on October 25, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department visit (99282) 
provided on July 6, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 per visit for emergency care.  
 
You have been asked to pay a $90 copayment for the emergency department visit provided. 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 department visit (99282) provided on July 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on May 16, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. 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 May 16, 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 by you on May 
16, 2020.