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

 
We decided that the Plan does not have to pay for the chest x-ray provided on June 23, 2020. 
 
You asked the Plan to pay for the chest x-ray (71045). You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says Original Medicare is responsible for this claim. 
 
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hospice election has been revoked or terminated.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 June 8, 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 chest x-ray provided on 
June 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 71275) provided on July 16, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that LCA A57061 provided a list of diagnosis codes 
that support medical necessity and provide limited coverage for CPT code 71275.  
 
We looked at the file and Medicare rules. The services in question were billed with diagnosis codes R79.89 and 
R55. These codes are not listed as covered ICD-10 codes for CPT 71275. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the services (CPT 71275) provided on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 2, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the enrollee's 
claim would be covered under Original Medicare. 
 
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 dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the medical services provided on May 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for cryosurgery services you received on June 
26, 2020. 
 
You asked the Plan to waive the deductible for the cryosurgery services. You say that you believe you are 
being overcharged for these services. The Plan denied your request. The Plan says you had not yet met your 
deductible when you had these cryosurgery services.  The deductible applies to outpatient surgical services 
such as cryosurgery. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 annual deductible that applies to outpatient surgery.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 annual 
deductible that applies to outpatient surgery services such as cryosurgery. This cost sharing is a contractual 
obligation that had not been met at the time the cryosurgery services was received on June 26, 2020. Therefore, 
we decided that the Plan does not have to waive the deductible for cryosurgery services you received on June 
26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 27, 
2020. 
 
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 the services were not an emergency, and prior authorization is required. 
 
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 laboratory services provided to the enrollee on 
April 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided on January 17, 2020 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that you were mailed a swab test kit. You say that you mailed it back for the lab test.The Plan denied your request. The Plan says prior authorization was not 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 forlab work provided on January 17, 2020 by an out of network (OON) provide
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on February 6, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services are available in-network.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 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 forthe medical services provided to the enrollee by an out-of-network provider on February 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProcrit.You asked the Plan to pre-approveProcrit. You say that you would like the Plan to reconsider their denial.The Plandenied your request. The Plan says Procrit to not be administered by a physician or supervised by a physician and supplied by a pharmacy is not covered under the enrollee's Medicare Part B benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveProcrit.Benefits for Procritmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided. 
 
You asked the Plan to pay for the home infusion therapy 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. 
 
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 S9328 is not supported in the medical record. Specifically, this code has a status code 
of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code 
for reporting and payment of this service. Based on this information, we decided that Medicare rules for 
coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy services coded S9328 provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on February 26, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing services provided on February 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance service (A0247) and ground 
mileage (A0425) provided. 
 
You asked the Plan to waive the copayment for ambulance and ground mileage. You say that the service was 
medically necessary. The Plan denied your request. The Plan says the cost share is correct. 
 
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 $240 
copayment for ambulance services.  
 
You have been asked to pay a $240 copayment for ambulance and ground mileage. This service falls within the 
Ambulance 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 ambulance service 
(A0247) and ground mileage (A0425) provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA) 
services provided to the enrollee on May 15, 2020. 
 
You asked the Plan to pay for the services. You say that this shoudl be paid for. The Plan denied your request. 
The Plan says screening testing is not a Medicare benefit for the diagnoses as listed on the claim and are done 
for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for infectious agent 
detection by nucleic acid (DNA or RNA) services provided to the enrollee on May 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion services (S9500) provided. 
 
You asked the Plan to pay for the home infusion services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the CPT code billed is not a covered service. 
 
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 S9500 is not supported in the medical record. Specifically, CPT code S9500 is marked 
with a status of "I" and is not valid for Medicare payment. Based on this information, we decided that Medicare 
rules for coverage of the home infusion services have not been met. Therefore, we decided that the Plan does 
not have to pay for home infusion services (S9500) provided.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Arthrocentesis provided on March 24, 2020 
 
You asked the Plan to pay for Arthrocentesis (20611). You say that the Plan should pay this claim The Plan 
denied your request. The Plan says there is no documentation of permanently recorded images to support the 
billed charge. 
 
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 20611 is Arthrocentesis, aspiration and/or injection, 
major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent 
recording and reporting.  
 
We find that CPT code 20611 is not supported in the medical record. Specifically, there is no permanent 
recording and reporting documentation in the file. Based on this information, we decided that Medicare rules 
for coverage of Arthrocentesis (20611) have not been met. Therefore, we decided that the Plan does not have to 
pay for Arthrocentesis provided on March 24, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases inwhich the Plan authorizes the use of out-of-network providers. You can find this information on pages 54 and 60-61 of the Plan's 2020 Evidence of Coverage.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 
19, 2020. 
 
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 the services were not authorized. 
 
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 laboratory services provided to the enrollee on 
September 19, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology service provided on July 8, 2020. 
 
You asked the Plan to pay for ophthalmology service. You say that you received a referral for this service, and 
you submitted this claim to the primary insurance carrier for payment. The Plan denied your request. The Plan 
says the denial of payment for this service is correct, because the Plan is the secondary payer for this enrollee 
and cannot process this claim until the Explanation of Benefits (EOB) from the primary insurance carrier is 
received. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
 
 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed 
that the primary insurance carrier had not yet processed this claim and advised you to submit the claim to the 
primary insurance carrier. As the secondary insurer, the Plan cannot be held responsible for ophthalmology 
service until the primary insurer has denied the claim for these services. A copy of the primary insurance 
carrier?s remittance advice should be submitted to the Plan, at which point the Plan may be able to process this 
claim. Therefore, we decided that the Plan does not have to pay for ophthalmology service provided on July 8, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on April 9, 2020 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the facility is also out-of-network.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 forphysician services provided on April 9, 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 the sterile water billed for services provided on April 10, 
2020. 
 
You asked the Plan to pay for the sterile water. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
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 physician order for the supplies provided in this case. 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 sterile water billed for services provided on April 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist hand orthosis (L3916) provided March 26, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the records provided should support the necessity of 
the service in dispute. The Plan denied your request. The Plan says the records do not support the service 
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 and an itemized shipping/billing invoice to indicate the 
specific supplies provided in this case. 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 
wrist hand orthosis (L3916) provided March 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 16, 2020 by an out of network (OON) provider.You asked the Plan to pay forlaboratory tests. You say that the enrollee was a resident of a nursing home and had no control over this lab work.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.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 forthe medical services provided on June 16, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided by January 29, 2019. 
 
You asked the Plan to pay for the outpatient services. You say that the claim was timely. The Plan denied your 
request. The Plan says the claim was untimely. 
 
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 outpatient 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 the outpatient services provided by January 29, 2019.