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

We decided that the Plan has to pay for laboratory testing provided on June 11, 2021.
You asked the Plan to pay for lab tests. You say that this testing was ordered to help determine the course of treatment for the enrollee. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because progress notes from the ordering physician are needed to determine the clinical utility of this testing.
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. This testing was ordered by an in-network physician. The file does not show that the plan provided notice that lab tests would not be covered. Under Medicare rules, this means lab tests is considered approved by the plan. Therefore, we decided that the Plan has to pay for laboratory testing provided on June 11, 2021.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (81479) rendered by the out-of-
network (OON) provider on May 15, 2020.
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 had network providers available
who could have provided 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 laboratory service (81479) rendered by the out-of-network (OON) provider on
May 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided
on December 4, 2020.
You asked the Plan to pay for the subsequent hospital care 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 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.
In this case, the CPT Code Manual definition of code 99232 is subsequent hospital care, per day, for the
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded
problem focused interval history; An expanded problem focused examination; Medical decision making of
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit.
We find that CPT code 99232 is not supported in the medical record. Specifically, medical records were not
provided for this date of service. This means this code is not supported by the documentation provided to the
Plan. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care
services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent
hospital care services coded 99232 provided on December 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (procedure code 99601) provided to the enrollee from February 26, 2021, to March 4, 2021.
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 this code is not valid for Medicare purposes.
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 99601 is "Home infusion/specialty drug administration, per visit (up to 2 hours)."
We find that CPT code 99601 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 home health services (procedure code 99601) provided to the enrollee from February 26, 2021, to March 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Arthrodesis, interphalangeal joint, with or without
internal fixation (26860) provided on June 15, 2021.
You asked the Plan to pay for code 26860. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the services are not covered as billed.
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 26860 is 1. The MAI value for this code is 2. You billed 2 units of this
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code
26860 have not been met. Therefore, we decided that the Plan does not have to pay for the Arthrodesis,
interphalangeal joint, with or without internal fixation (26860) provided on June 15, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on
June 6, 2021.
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says code 99284 is more appropriate for the
services rendered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation
and management of a patient, which requires these 3 key components within the constraints imposed by the
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high
severity and pose an immediate significant threat to life or physiologic function.
We find that CPT code 99285 is not supported in the medical record. Specifically, the documentation does not
support that the presenting problem(s) are were of high severity. This means that this code was not supported
by the documentation provided. Based on this information, we decided that Medicare rules for coverage of the
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the
emergency department visit coded 99285 provided on June 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on
August 13, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 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 out of network medical services provided to the
enrollee on August 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan services provided on June 3, 2021.
You asked the Plan to pay for the duplex scan services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that All ICD-10 codes not listed under the "ICD-10
Codes that Support Medical Necessity" section of the article do not support medical necessity.
We looked at the file and Medicare rules. The rules say that specific diagnosis codes are covered for duplex
scan services. The duplex scan services were billed with diagnosis code I10. This diagnosis code is not listed as
one that meets medical necessity for the services rendered. This means this service is not covered. Based on
this information, we decided that Medicare rules for coverage of the duplex scan services have not been met.
Therefore, we decided that the Plan does not have to pay for the duplex scan services provided on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the
additional periapical x-ray (D0230) provided on August 20, 2021.
You asked the Plan to pay for the dental services. You say that you are a new patient with this dentist. You say
that your previous dentist is no longer in network so you had to find a new one. You also say that you feel the
services should be covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is
covered every 3 calendar years. The Plan says that 1 periapical x-ray is covered per calendar year. The Plan
also says that the frequency limits for these services have been exceeded.
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 and the services are listed as covered,
the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral
evaluation that you received on June 3, 2020. The record shows that the Plan paid for a periapical x-ray that
you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation (D0150) and the additional periapical x-ray (D0230) provided on August 20,
2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (procedure code 70450) provided to the enrollee on August 23, 2021.
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 this is an unbundled 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. In this case, we have confirmed that code 70450 is a column II code to column I code 70496. 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 imaging services (procedure code 70450) provided to the enrollee on August 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for inpatient hospital care provided from June
12, 2021, to July 21, 2021.
You asked the Plan to waive the copayments for inpatient hospital care. You say that you suffer from long
coronavirus symptoms and the hospital stays were related to you having had the coronavirus. 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 $325
copayment for days 1-6 for inpatient hospital care.
You received inpatient hospital care from June 12, 2021, to June 16, 2021. The coronavirus waiver does not
apply to this stay. Therefore, you are responsible to pay a $325 copayment for days 1-4 (June 12, 2021, to June
15, 2021). The total amount you owe for this stay is: $325 (copayment) x 4 (inpatient days) = $1,3000.
You received inpatient hospital care from July 17, 2021, to July 21, 2021. The coronavirus waiver does not
apply to this stay. Therefore, you are responsible to pay a $325 copayment for days 1-4 (July 17, 2021, to July
20, 2021). However, you are only responsible to pay $975, which is less than the total copayment amount.
The total amount you owe is: $2,275.
You have been asked to pay the total copayment amount of $2,275 for inpatient hospital care. Inpatient hospital
care falls within the inpatient hospital care benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments
for inpatient hospital care provided from June 12, 2021, to July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on July
16, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that the injections did not
work and 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 20%
coinsurance for Medicare Part B prescription drugs.
You received Medicare Part B drugs on July 16, 2021. The total allowed amount is $1,106.56 and 20% of that
is $221.32.
You have been asked to pay the total coinsurance amount of $221.32 for Medicare Part B drugs. Medicare Part
B drugs fall within the Medicare Part B prescription drugs 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 Medicare Part B drugs provided on July 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the wrist/hand brace and the occupational
therapy visit you received on August 17, 2021.
You asked the Plan to waive the cost sharing for the brace and the occupational therapy visit. You say that you
do not understand why you have to pay this amount out-of-pocket. The Plan denied your request. The Plan says
you were charged this cost sharing 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 prosthetic devices and related
supplies (including braces) and a $30 copayment for occupational therapy services.
You have been asked to pay 20% coinsurance for the brace and a $30 copayment for the occupational therapy
visit. The brace falls within the prosthetic devices and related supplies (including braces) benefit category. This
means that you have been asked to pay the correct amounts 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 cost sharing for the wrist/hand brace and the occupational therapy visit you
received on August 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on
August 30, 2021.
You asked the Plan to pay for the x-ray 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 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. In this case, we have confirmed that code 71045
for the x-ray services is a column II code to column I code 71046. 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 the x-ray services coded 71045 provided on
August 30, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that you feel that this is necessary. The Plan denied your request. The Plan says the enrollee's needs are custodial in nature and coverage criteria for SNF care are not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is not shown to have an acute decline in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of care. 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair of tendon or muscle services coded 24341
provided on
You asked the Plan to pay for the repair of tendon or muscle 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 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.
In this case, the CPT Code Manual definition of code 24341 is repair, tendon or muscle, upper arm or elbow,
each tendon or muscle, primary or secondary (excludes rotator cuff).
We find that CPT code 24341 is not supported in the medical record. Specifically, the operative report did not
include documentation of a primary or secondary repair of the tendon or muscle for the upper arm or elbow, for
each tendon or muscle, (excludes rotator cuff); therefore, this code cannot be verified. Based on this
information, we decided that Medicare rules for coverage of the repair of tendon or muscle services have not
been met. Therefore, we decided that the Plan does not have to pay for the repair of tendon or muscle services
coded 24341 provided on
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reimburse you the full $200 eyewear benefit amount for eyeglasses provided
on July 22, 2021.
You asked the Plan to reimburse you the full $200 eyewear benefit amount for the eyeglasses. The Plan denied
your request. The Plan says that you were reimbursed the correct amount after a withhold was applied to the
claim.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services In-Network and Out-of-Network with a $200 allowance.
We looked at the file and the Plan's rules. The file shows that the Plan routine eyewear benefit covers these
services In-Network and Out-of-Network with a $200 allowance. The Plan's EOC does not state there is a
"withhold" under the routine eyewear benefit. Therefore, we decided that the Plan has to reimburse you the full
$200 eyewear benefit amount for eyeglasses provided on July 22, 2021.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on
December 10, 2020.
You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan
says per your Evidence of Coverage and due to the store discount applied for the eyeglasses, you were
eligible for the $90 reimbursement, which was applied by the provider. Your plan does not include a return or
refund policy.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine 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. The file shows that sale items are excluded, and this benefit cannot
be combined with any other store discounts, coupons, or promotional codes. Your Plan does not include a
return or refund policy. Therefore, we decided that the Plan does not have to pay an additional amount for
eyeglasses provided on December 10, 2020.