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

 
We decided that the Plan does not have to pay for the laboratory services coded 80053, 80197, 82550, 83880, 
85025, 85347, and 87497 provided on March 5, 2020 and March 6, 2020. 
 
You asked the Plan to pay for the laboratory 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80053, 80197, 82550, 83880, 85025, 85347, and 87497 are not supported in the 
medical record. Specifically, these services were billed with an indicator of 9. These services are reimbursable 
to the facility. When facilities obtain manual or automated laboratory tests for patients under arrangements with 
an Independent Laboratory, Reference Laboratory or pathology group, only the facility may be reimbursed for 
the services. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 
80053, 80197, 82550, 83880, 85025, 85347, and 87497 provided on March 5, 2020 and March 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic digital breast tomosynthesis coded 77062 
provided on January 23, 2020. 
 
You asked the Plan to pay for the diagnostic digital breast tomosynthesis. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 77062 is diagnostic digital breast tomosynthesis; 
bilateral. 
 
We find that CPT code 77062 is not supported in the medical record. Specifically, this code has a status code of 
"I". Status code I means that this code is not valid for Medicare purposes. Medicare uses another code for 
reporting of, and payment of these services. Based on this information, we decided that Medicare rules for 
coverage of the diagnostic digital breast tomosynthesis have not been met. Therefore, we decided that the Plan 
does not have to pay for the diagnostic digital breast tomosynthesis coded 77062 provided on January 23, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the additional extraction provided on October 4, 2019. 
 
You asked the Plan to pay for the additional extraction. You say that you needed the dental work done which 
was prescribed by your regular dentist. The Plan denied your request. The Plan says that you have a frequency 
limitation of only two extractions per year, and this benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a copy of the applicable 2019 Evidence of Coverage 
for this case. We asked for this document, but it was not provided to us. Without this information we cannot 
determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been 
adequately notified of the Plan's coverage rules and benefits. Consequently, the Plan has not substantiated their 
denial of payment in this case. Therefore, we decided that the Plan has to pay for the additional extraction 
provided on October 4, 2019.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from 
February 22, 2020 to April 7, 2020. 
 
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you disagree with the 
charges because you were never charged in the past. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for DME and related supplies.  
 
You received DME and related supplies from February 22, 2020 to April 7, 2020. The total allowed amount is 
$222.30 and 20% of that is $44.40.  
 
You have been asked to pay the total coinsurance amount of $44.40 for DME and related supplies. DME and 
related supplies fall within the DME and related supplies 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 DME and related supplies provided from February 22, 2020 to April 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridement (11721) and the subsequent nursing 
facility care, per day (99308) rendered by the out of network (OON) provider on December 6, 2019 and 
February 14, 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 the services were rendered by an out of 
network provider, without 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 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 services at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for the nail debridement (11721) and the subsequent nursing facility care, per day (99308) 
rendered by the out of network (OON) provider on December 6, 2019 and February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on February 5, 
2020. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on February 5, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 28, 2020 by an out of 
network (OON) provider. 
 
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 rendered by an out-of-network provider without 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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on April 28, 2020 
by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided February 15, 
2019. 
 
You asked the Plan to pay for the emergency room services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claim was not filed timely. 
 
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 room services was not filed until May 11, 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 emergency room services (99285) provided February 15, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 24, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit services provided on January 23, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the rest home visit services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 rest home visit services provided on January 
23, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an office visit and an ultrasound provided 
on March 12, 2020. 
 
You asked the Plan to waive the copayments for an office visit and an ultrasound. You say that you should not 
owe a copayment for the office visit because of COVID-19 and you were not informed that you would owe a 
copayment for the ultrasound. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
copayment for primary care provider visits. Your contract with the Plan also clearly says that you must pay a 
$95 copayment for each radiological diagnostic services.  
 
You had an office visit on March 12, 2020. Therefore, you are responsible to pay the $5 copayment.  
 
You had an ultrasound on March 12, 2020. Therefore, you are responsible to pay the $10 copayment.  
 
The total amount you owe is: $15.  
 
You have been asked to pay the total copayment amount of $15 for an office visit and an ultrasound. An office 
visit falls within the physician/practitioner services, including doctor's office visits benefit category. An 
ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an office visit and an ultrasound provided on March 12, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance provided on February 5, 2020 
by an OON provider. 
 
You asked the Plan to pay for the periodontal maintenance. The Plan denied your request. The Plan says the 
service was rendered by an OON 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, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance provided on February 5, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the 
enrollee on November 4, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 remains not supported. 
 
The Plan must follow Medicare rules. The rules say that the physician must clearly document, in the medical 
record, his or her intent that the test be performed. 
 
There is no evidence of a valid physician order in the case file. 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 drug testing services (HCPCS G0483) provided to the enrollee on November 4, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99307) rendered by the 
out of network (OON) provider on June 29, 2019. 
 
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 service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service 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 this service. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care (99307) rendered by the out of network (OON) provider on 
June 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgently needed services provided on July 
7, 2020. 
 
You asked the Plan to waive the copayment for urgently needed services. You say that you disagree with the 
charges because an urgent care facility was closed early. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for urgently needed services.  
 
The medical records show that you received urgently needed services on July 7, 2020. Therefore, you are 
responsible to pay the $50 copayment.  
 
You have been asked to pay a $50 copayment for urgently needed services. Urgently needed services fall 
within the urgently needed services 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 
urgently needed services provided on July 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of skin substitute graft to face, scalp, eyelids, 
mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm 
services coded 15275 provided on April 16, 2020. 
 
You asked the Plan to pay for the application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, 
orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 
are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 15275 is 1. You billed 45 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the application of skin substitute graft to face, 
scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area 
up to 100 sq cm have not been met. Therefore, we decided that the Plan does not have to pay for the application 
of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple 
digits, total wound surface area up to 100 sq cm services coded 15275 provided on April 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 28, 2020. 
 
You asked the Plan to pay for the services provided. You say that the medical records support the lab services. 
The Plan denied your request. The Plan says there is no evidence of a relationship with the ordering physician. 
 
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 G0481 is definitive drug testing of 8-14 drug classes. We 
find that CPT code G0481 is not supported in the medical record. There is insufficient information to show the 
testing was ordered for a specific medical problem. Tests not ordered by the physician who is treating the 
beneficiary are not reasonable and necessary. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the lab services provided on February 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 15, 2020. 
 
You asked the Plan to pay for the lab services. You say that the plan is responsible for the date at issue. The 
Plan denied your request. The Plan says Original Medicare is responsible for the charges. 
 
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 January 9, 2020. The services in question were provided 
before the end of that month. Original Medicare is responsible for payment for services until the first day of the 
month after the hospice election has been revoked. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on January 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a back brace (L0650) received on January 
5, 2019. 
 
You asked the Plan to waive the coinsurance for a back brace. You say that you are on a fixed income and 
cannot afford this item. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay $271.80, or 20% coinsurance of the Plan-allowed amount of $1,358.99, for a back 
brace. A back brace falls within the "Durable medical equipment (DME) and related supplies" 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 a back brace (L0650) received on January 5, 2019.  
 
Your complaint about the provider's office not accepting a return of the item you purchased or returning your 
calls 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.