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

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on December 2, 2019.
You asked the Plan to pay for the drug testing. 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 supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition form or medical records stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hospital-based weight loss program for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says hospital-based weight loss services provided by a specialist physician are not covered by Medicare or the plan.
The Plan must follow Medicare rules. Medicare rules say that intensive behavioral therapy for obesity is covered when furnished by a qualified primary care physician or other primary care practitioner and in a primary care setting. The requested services are to be provided in a hospital with a bariatric medicine specialist. These services are only covered in a primary care setting. Based on this information, we decided that Medicare rules for coverage of the therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve a hospital-based weight loss program for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services (99238) provided March 6, 2019. You asked the Plan to pay for the hospital discharge services. You say that your claim was denied as another provider was paid on this date of service. The service provided by your physician is separately identifiable form the procedures performed by any other provider. The Plan denied your request. The Plan says more than one discharge service was billed for the same date of service. Only one hospital discharge day management service is payable per patient per hospital stay. In addition only the attending physician of record reports the discharge day management service.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. The enrollee was an inpatient, therefore all services provided to the enrollee will be paid under the global facility claim. Payment for the physician service would have been included under the facility claim. Payment to the physician for this service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services (99238) provided March 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit you had on December 3, 2019.
You asked the Plan to pay for the visit. You say that this was not an annual wellness visit. The Plan denied
your request. The Plan says this is only covered once every 12 months.
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 $0
copayment for an annual wellness visit once every 12 months.
Review of the file shows that you had an annual wellness visit on December 3, 2019. The records also show
that you had an annual wellness visit on December 3, 2019, which was paid by the plan. As an annual wellness
visit is only covered once every 12 months, the requested visit exceeds the benefit limit. This means that you
have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the
Plan does not have to pay for the annual wellness visit you had on December 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased on March 10, 2020 from an out-ofnetwork
provider.
You asked the Plan to pay for the eyewear. You say that their glasses are cheaper than at other providers. The
Plan denied your request. The Plan says you do not have out-of-network benefits.
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.
Review of the file show that you purchased the eyewear on March 10, 2020 from an out-of-network provider.
Your EOC states, there is a $150 limit for eyewear every twelve (12) months from a participating supplemental
vision provider. 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 preapprove
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 purchased on March
10, 2020 from an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel
to the nursing home provided on December 10, 2019.
You asked the Plan to pay for the transportation of portable x-ray equipment and personnel to home or nursing
home (R0700). You say that the Plan should pay this claim. The Plan denied your request. The Plan says
R0070 is a technical component only code and not separately 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.
Specifically the enrollee was in a nursing home so the claim is not separately payable. Based on this
information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment and
personnel to home or nursing home (R0700) have not been met. Therefore, we decided that the Plan does not
have to pay for the transportation of portable x-ray equipment and personnel to the nursing home provided on
December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for hearing services provided from January 7,
2020 to February 4, 2020.
You asked the Plan to waive the copayments for hearing services. You say that you disagree with the charges.
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 $65
copayment for out-of-network hearing services.
You received hearing services on January 7, 2020 from an out-of-network provider. Therefore, you are
responsible to pay the $65 copayment.
You received hearing services on January 28, 2020 from an out-of-network provider. Therefore, you are
responsible to pay the allowed amount of $56.56, which is less than the $65 copayment.
You received hearing services on February 4, 2020 from an out-of-network provider. Therefore, you are
responsible to pay the allowed amount of $30.03, which is less than the $65 copayment.
The total amount you owe is: $151.59.
You have been asked to pay the total copayment amount of $151.59 for hearing services. Hearing services fall
within the hearing 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 copayments for hearing
services provided from January 7, 2020 to February 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services.
You asked the Plan to pay for the paramedic intercept services. You say that you want to appeal the Plan's
denial of the services. You say that you are on a fixed income and you asked the Plan to reconsider their denial .
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 pays for advanced life support (ALS), in
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMTParamedic
only in certain circumstances. Medicare allows ALS paramedic intercept services only when the
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow
the volunteer ambulance company to bill for the transport or BLS services.
The Plan has confirmed that the paramedic intercept provider does not have a contract with the volunteer
ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to
pay for the paramedic intercept services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic screening testing (CPT 87631) provided to the enrollee on March 9, 2020.
You asked the Plan to pay for the testing. You say that The Plan denied your request. The Plan says this code is not covered by Medicare and is excluded from coverage.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 testing. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the documentation is limited, and does not support that molecular genetic screening testing (nucleic acid assays that detect multiple respiratory viruses in a multiplex reaction) was medically reasonable and necessary for the enrollee in this case. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for molecular genetic screening testing (CPT 87631) provided to the enrollee on March 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on January 16, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and approved
for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says
that the member's primary care physician did not refer these services.
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 lab services provided on January 16, 2020 by an
out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a portable oxygen concentrator and related supplies
purchased October 16, 2019 through November 1, 2019.
You asked the Plan to pay for the DME. You say that you contacted the Plan prior to purchasing the DME and
were told that the item was covered under your plan. The Plan denied your request. The Plan says you were
informed that the portable oxygen concentrator is covered as a rental only. The Plan states you were advised to
submit prescription to a different provider to get the process started for rental of the portable oxygen
concentrator.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. The plan will only cover the rental of
oxygen devices from approved suppliers and will not cover the cost of purchasing a portable oxygen
concentrator. Therefore, we decided that the Plan does not have to pay for a portable oxygen concentrator and
related supplies purchased October 16, 2019 through November 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for syringe with needle for external insulin pump, sterile, 3 cc
(A4232) provided on January 24, 2020.
You asked the Plan to pay for the DME. You say that you have been getting this item approved through
Medicare. You state that you cannot receive your insulin if this claim is not paid. The Plan denied your request.
The Plan says this code is not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
Based on this information, we decided that Medicare rules for coverage of the DME have not been met. This
code is not covered by Medicare. The Plan states they spoke with the provider and the provider incorrectly had
you as a commercial patient rather than a Medicare patient and the codes are different. The Plan states the
provider with resubmit the claim with the correct Medicare code. Therefore, we decided that the Plan does not
have to pay for syringe with needle for external insulin pump, sterile, 3 cc (A4232) provided on January 24,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214), a pontic (D6241),
and retainer crowns (D6751).
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The
Plan denied your request. The Plan says rules for coverage have not been met.
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. The Plan covers the dental
services when the services are medically necessary and reasonable.
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 the dental services. Our reviewer says
that the requested services are not medically necessary. Our physician reviewer found in this instance the
enrollee has 12 posterior teeth in contact, exceeding the minimum allowable to consider a partial denture.
Given the Plan limitations, there would be no medical necessity for the requested partial denture. There has
been no documentation of a cleft palate condition or any other physical or neurological condition that would
allow coverage of a pontic within the terms of the plan contract. The requested retainer crowns are not
medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does
not have to pre-approve a mandibular partial denture (D5214), a pontic (D6241), and retainer crowns (D6751).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on January 23, 2020.
You asked the Plan to waive the copayment for an X-ray. You say that you should only owe a $10 copayment
and disagree with the additional charges. 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 $45
copayment for basic radiological services provided in a specialist's office visits.
You have been asked to pay the allowed amount of $32.26, which is less than the $45 copayment for an X-ray.
An X-ray 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 copayment for an X-ray provided on January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingles vaccines (90750) and administration (90471)
provided on December 26, 2019 and February 28, 2020.
You asked the Plan to pay for a shingles vaccines and administration. You say that you should not be billed for
these vaccines. The Plan denied your request. The Plan says these vaccines are not covered under your Plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccines
and administration. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccines
and administration. Therefore, we decided that the Plan does not have to pay for a shingles vaccines (90750)
and administration (90471) provided on December 26, 2019 and February 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased on November 21, 2019 from a nonparticipating
provider.
You asked the Plan to pay for the eyewear. You say that the frame broke and could not be replaced as they
were no longer being made. You state that you then purchased new lenses and that you could not order new
frames only. The Plan denied your request. The Plan says you exhausted your maximum benefit allowance.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case.
We looked at the file and the Plan's rules. You had exceeded the Maximum Allowance amount for eyewear, are
responsible for any and all amounts over that maximum amount of $300.00. Therefore, we decided that the
Plan does not have to pay for the eyewear purchased on November 21, 2019 from a non-participating provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the SNF stay and physical therapy
provided from July 1, 2019 to August 2, 2019.
You asked the Plan to waive the copayments for the SNF stay and the physical therapy. You say that you
should not be responsible for the copayments and you say you cannot afford these charges. The Plan denied
your request. The Plan says you have been charged the correct cost sharing 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 $0
copayment per day, days 1-20 and a $160 copayment per day, days 21-100 for each in-network SNF stay, after
you pay your $1,000 deductible and a $40 copayment for Medicare-covered in-network occupational and
physical therapy services.
You have been asked to pay a $1,760 for the SNF stay and a $40 copayment per date of service for the physical
therapy. ($40 x 12 = $280). The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit
category. The physical therapy falls within the "Outpatient rehabilitation 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 copayments for the SNF stay and physical therapy provided from July 1,
2019 to August 2, 2019.
Your complaint that you did not see a physician and that the therapy did not produce results are not valid
appeals 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan services coded 72125 provided on January 28,
2020.
You asked the Plan to pay for the CT scan services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed exceed the MUE value for this code.
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 72125 is 1. You billed this service/code twice, exceeding the MUE. Based
on this information, we decided that Medicare rules for coverage of the CT scan services have not been met.
Therefore, we decided that the Plan does not have to pay for the CT scan services coded 72125 provided on
January 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a nuclear stress test provided on March 5,
2020.
You asked the Plan to waive the copayment for a nuclear stress test. You say that you were told your
copayment would be $45. 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 $350
copayment for nuclear medicine services provided in an outpatient hospital.
You have been asked to pay a $350 copayment for a nuclear stress test, a nuclear medicine service provided in
an outpatient hospital. 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 a nuclear stress test provided on
March 5, 2020.