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

 
We decided that the Plan does not have to pay for procedure code 47379 billed for date of service April 18, 
2022. 
  You asked the Plan to pay for procedure code 47379. You say that the operative report for procedure code 
47379 is attached and the claim should be reprocessed for payment. The Plan denied your request. The Plan 
says payment for code 47379 is bundled into payment for code 76998. 
 
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, we have confirmed that code 47379 
is a column II code to column I code 76998. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 47379 billed for date of service April 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport services 
received on July 12, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment, no transport services. You say that you 
couldn't breathe so you called the ambulance. You also say that you were instructed to call 911 if you had an 
emergency. The Plan denied your request. The Plan says the services received 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 July 12, 2022. 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 response and treatment, no 
transport services received on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014), deluxe eyeglass frames (V2025), 
single eyeglass lens (V2100), and tint for eyeglass lens (V2745) provided by an out-of-network on June 14, 
2022. 
 
You asked the Plan to pay for the eye exam (92014), deluxe eyeglass frames (V2025), single eyeglass lens 
(V2100), and tint for eyeglass lens (V2745). You say that you attempted to find a network vision provider, but 
the portal would not work properly. You say you went to your previous provider, and you do not want to 
change providers. The Plan denied your request. The Plan says the provider was out-of-network. 
 
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. The Plan covers these services when provided by in-network providers. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the eye exam (92014), deluxe eyeglass frames 
(V2025), single eyeglass lens (V2100), and tint for eyeglass lens (V2745) have not been met. Therefore, we 
decided that the Plan does not have to pay for the eye exam (92014), deluxe eyeglass frames (V2025), single 
eyeglass lens (V2100), and tint for eyeglass lens (V2745) provided by an out-of-network on June 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an acute inpatient hospital stay provided to the enrollee on 
July 13, 2022, and July 14, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says the record does not support an acute care admission. The enrollee 
could have been observed for a period of time, and then discharged with outpatient follow-up. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the review has determined that the record did not show that at the time of 
inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care 
(including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for an acute inpatient hospital stay provided to the enrollee on July 13, 2022, and 
July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit, the removal of a nail plate, the trim of a skin 
lesion, and the debridement of nails provided on June 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a home visit, the removal of a nail plate, the trim of a skin lesion, and the 
debridement of nails. You say that at the time of service, the member informed you that he/she is covered under 
Medicare. You also say that it was impossible to obtain authorization, due to the member misleading you with 
the incorrect insurance information. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan and there is not an approved 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 had network providers 
available who could have provided 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 a home visit, the removal of a nail plate, the trim 
of a skin lesion, and the debridement of nails provided on June 1, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment of methadone (G2067) and a 
take home supply of methadone (G2078) provided on April 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for medication assisted treatment of methadone (G2067) and a take home supply of 
methadone (G2078). You say that this facility is an opioid treatment program (OTP) clinic. You also say that 
no authorization is required for federally qualified health centers (FQHC) tribal OTP facilities due to the 
patient's not making appointments, but coming in when they decide to seek treatment, per the Centers for 
Medicare and Medicaid Services (CMS). The Plan denied your request. The Plan says the member does not 
have out of network benefits. The Plan also says that there is no documentation this member was referred to 
this non-contracted provider by a contracted provider, as well as no indication any attempt was made to obtain 
prior authorization for the out of network  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 had network providers 
available who could have provided 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 medication assisted treatment of methadone 
(G2067) and a take home supply of methadone (G2078) provided on April 4, 2022, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (97010, 97032) provided on June 6, 
2022. 
 
You asked the Plan to pay for the chiropractic services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services (97010, 97032) provided on June 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the factor II gene analysis received on June 23, 2022. 
 
You asked the Plan to pay for the factor II gene analysis. You say that you were told that this service would 
cost you $150. The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that F2 genetic testing is only covered for enrollees 
who are pregnant. 
 
We looked at the file and Medicare rules. Review of the file did not support that you met the criteria of being 
pregnant. Based on this information, we decided that Medicare rules for coverage of the factor II gene analysis 
have not been met. Therefore, we decided that the Plan does not have to pay for the factor II gene analysis 
received on June 23, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on February 10, 2022. 
 
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 that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on February 10, 2022.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit provided on July 01, 
2022. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that all COVID-19 treatments 
are free. You say that you dont understand why you were billed for an emergency room visit when you had an 
appointment for an infusion. The Plan denied your request. The Plan says this cost sharing was charged 
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 $120 
copayment for emergency care. 
 
You have been asked to pay a $120 copayment for emergency room visit. This item/service falls 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. The records show that services were provided in the emergency department. Therefore, we decided that 
the Plan does not have to waive the copayment for emergency room visit provided on July 01, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (99211, 90833) provided on June 2, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99211 & 90833 is not supported in the medical record. Specifically, the codes billed 
have a status of "B" and are not recognized by the Outpatient Prospective Payment System (OPPS). Based on 
this information, we decided that Medicare rules for coverage of the outpatient services have not been met. 
Therefore, we decided that the Plan does not have to pay for outpatient services (99211, 90833) provided on 
June 2, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on March 22, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was not enrolled in hospice 
until after the ambulance transport took place. The Plan denied your request. The Plan says the enrollees claim 
would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the 
date of election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing 
procedures for a Medicare Advantage member on hospice. 
 
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 ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telephone or internet assessment service provided on April 
21, 2022. 
 
You asked the Plan to pay for the telephone or internet assessment service. You say that the records show the 
provider is Medicare eligible. The Plan denied your request. The Plan says an RN is not eligible to enroll in 
Medicare and a provider can only be paid if they are enrolled in Medicare, so RN is not payable. 
 
The Plan follows Medicare rules. Medicare rules state that a Registered Nurse (RN) is not eligible to enroll in 
the Medicare program and is not payable. 
 
 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 a telephone or internet assessment service provided on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110), provided on August 25, 2022. 
 
You asked the Plan to pay for the dental cleaning. You say that you did not know the provider was out-of-
network. The Plan denied your request. The Plan says dental services must be obtained through an in-network 
provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Specifically, you obtained this service out-of-network. Therefore, we 
decided that the Plan does not have to pay for the dental cleaning (D1110), provided on August 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Rubidium Rb-82 (A9555), provided on 
January 18, 2022. 
 
You asked the Plan to waive the coinsurance for the Rubidium Rb-82. You say that the cost share is incorrect. 
The Plan denied your request. The Plan says this cost sharing was charged 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 20% 
coinsurance for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay 20% coinsurance for the Rubidium Rb-82. This item 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 coinsurance for the Rubidium Rb-82 (A9555), provided on January 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation (A0425, A0428) provided on May 
31, 2022. 
 
You asked the Plan to pay for the ambulance transportation. You say that the service was medically necessary. 
The Plan denied your request. The Plan says insufficient documentation was provided to support payment for 
this service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the ambulance transportation have 
been met. No medical records were submitted to show this service was medically necessary. The plan 
requested records from the ambulance provider and none were provided. Therefore, we decided that the Plan 
does not have to pay for ambulance transportation (A0425, A0428) provided on May 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the radiological examination, provided on 
January 21, 2022. 
 
You asked the Plan to waive the copayment for the radiological examination. You say that there should not be 
a cost share. The Plan denied your request. The Plan says this cost sharing was charged 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 an $85 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $81.02 out of an $85 copayment for the radiological examination. This 
item/service 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 the radiological examination, provided on January 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service April 15, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that the medical records show the necessity of 
the additional units of this service. The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service April 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on June 24, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that since you had to move 
hospitals to receive help you shouldnt have to pay for this. The Plan denied your request. The Plan says this 
cost sharing was charged 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 $325 
copayment for Ambulance services. 
 
You have been asked to pay a $325 copayment for ambulance transport. This item/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 transport 
provided on June 24, 2022.