Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the esophagogastroduodenoscopy (EGD) 
procedure you had at an outpatient hospital facility on June 11, 2021. 
 
You asked the Plan to reduce the copayment for the EGD. You say that when you have had this procedure in 
the past, you have only paid the office visit copayment. The Plan denied your request. The Plan says you were 
charged this copayment correctly.  The Plan says that they have no prior claims for you for this procedure 
where you were only charged an office visit copayment. 
 
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 outpatient surgery and services at an outpatient hospital facility.  
 
 You have been asked to pay a $325 copayment for the EGD. The EGD falls within the outpatient surgery and 
services at an outpatient hospital facility 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 reduce the copayment 
for the esophagogastroduodenoscopy (EGD) procedure you had at an outpatient hospital facility on June 11, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoroscopic guidance (77003) provided on March 16, 2021. 
 
You asked the Plan to pay for fluoroscopic guidance 77003. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 77003 is bundled for payment with code 22870 and these codes should not be billed together on the same 
date of 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 
fluoroscopic guidance 77003 is a column II code to column I code 22870. 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 fluoroscopic guidance (77003) provided 
on March 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical shoulder debridement (29823-59) provided on April 
28, 2021. 
 
You asked the Plan to pay for surgical shoulder debridement. You say that this is supported in the records. The 
Plan denied your request. The Plan says this cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service.  Specifically, the records shows that this service was performed on the same shoulder during the same encounter 
as the other billed procedures. Based on this information, we decided that Medicare rules for coverage of 
services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay 
for surgical shoulder debridement (29823-59) provided on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on July 14, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that the charge for this exam should be included in the treatment of the tooth. The Plan denied your request. The Plan says this service exceeds the coverage limits.

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, you are limited to two oral examinations per calendar year. The record shows that you received oral exams on May 5, 2021, and May 11, 2021 and your oral examinations benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on July 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on April 14, 2021. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like reconsideration 
based on the documents submitted. The Plan denied your request. The Plan says HCPCS code 19285 denied 
due to lack of reporting of a device category HCPCS code required for the billed procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that the Outpatient Code Editor (OCE) will return to 
the provider any claim that reports a Healthcare Common Procedure Coding System (HCPCS) for a procedure 
assigned to a device-intensive APC, for which the procedure requires the implantation of a device that does not 
also report at least one device HCPCS code required for that procedure. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient hospital services have not been met. Specifically, this claim includes a device 
intensive HCPCS code. This claim has not been billed with a device category HCPCS code. Therefore, we 
decided that the Plan does not have to pay for the outpatient hospital services provided on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on February 1, 2021.

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 office visit (99203) rendered by the out-of-network (OON) provider on February 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, foot (73620) provided June 15, 2021.

You asked the Plan to pay for the diagnostic service provided. You say that please review attached records for reconsideration. The Plan denied your request. The Plan says this service is bundled to another service billed on the same day by the same provider.

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 the diagnostic service provided is a column II code to column I code 73630-26, RT. 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 radiologic examination, foot (73620) provided June 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic radiation treatments (77014, 77523) provided on 
March 5, 2021. 
 
You asked the Plan to pay for therapeutic radiation treatments. You say that the enrollee is a participant in an 
approved clinical trial. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the Plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pay for therapeutic radiation treatments as part of a clinical trial. The Plan 
contract states that enrollees must pay 20% coinsurance for Medicare-covered therapeutic radiology. This is 
equal to the cost-sharing under Original Medicare. There is no difference between the cost-sharing in Original 
Medicare and the Plan cost-sharing for the same services. Therefore, we decided that the Plan does not have to 
pay for therapeutic radiation treatments (77014, 77523) provided on March 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) provided on June 
8, 2021. 
 
You asked the Plan to pay for the removal of residual tooth roots. You say that the hygienist pulled back the 
filling on your tooth and put it back, but you eventually lost it two weeks later. The Plan denied your request. 
The Plan says this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
removal of residual tooth roots (D7250) provided on June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the breast prosthesis and mastectomy bra 
you received from an out-of-network provider on May 13, 2021. 
 
You asked the Plan to waive the deductible for the out-of-network breast prosthesis and mastectomy bra. You 
say that your breast surgeon told you that your Plan covered mastectomy bras and prostheses.  You said that the 
provider assured you that this would be covered 100%. The Plan denied your request. The Plan says you were 
charged this deductible correctly. 
 
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 $1500 deductible which applies to out-of-network prostheses and 
supplies.  
 
You received the prosthesis and the bra from an out-of-network provider. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $1500 deductible which applies to out-of-network 
prostheses and supplies. This cost sharing is a contractual obligation that had not been met at the time the out-
of-network breast prosthesis and mastectomy bra were received on May 13, 2021. The Plan cannot be held responsible for incorrect information provided to you by an out-of-network provider. Therefore, we decided 
that the Plan does not have to waive the deductible for the breast prosthesis and mastectomy bra you received 
from an out-of-network provider on May 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy (36475). 
 
You asked the Plan to pre-approve endovenous ablation therapy. You say that this is medically necessary. The 
Plan denied your request. The Plan says the submitted records do not include required imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that invasive procedures for the treatment of varicose 
veins are considered medically reasonable and necessary when a duplex scan of the deep and superficial 
venous systems supports the examination findings and a duplex scan confirms the presence of reversed venous 
flow (reflux) with provocative maneuvers in the saphenous, or perforator veins is 500 milliseconds or greater3 
and absence of deep venous obstruction. 
 
We looked at the file and Medicare rules. The submitted medical records do not include documentation of 
duplex scans. Based on this information, we decided that Medicare rules for coverage of endovenous ablation 
therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous 
ablation therapy (36475).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (G0480, 84228, 82542) rendered by the out-of-network (OON) provider on June 7, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (G0480, 84228, 82542) rendered by the out-of-network (OON) provider on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on November 9, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 01610 is not supported. 
 
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 01610 is anesthesia for all procedures on nerves, muscles, 
tendons, fascia, and bursae of shoulder and axilla. 
 
We find that CPT code 01610 is not supported in the medical record. Specifically, there is no documentation of 
an anesthesia record to support the billing of these services.  
 Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia services rendered on November 9, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (84443) provided March 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the claim is a duplicate. 
 
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 84443 is not supported in the medical record. Specifically, the same code was billed on 
the same date of service and was paid under claim number 820210920101797. The records do not support that 
this was a separate service. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (84443) 
provided March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Positron Emission Tomography (PET) scan (78815) 
provided May 11, 2021. 
 
You asked the Plan to pay for the PET scan. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim did not include a valid diagnosis code. 
 
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 78815 is not supported in the medical record. Specifically, C50.912 (Malignant 
neoplasm of unspecified site of left female breast) is not listed as a valid diagnosis code for this service. Based 
on this information, we decided that Medicare rules for coverage of the PET scan have not been met. 
Therefore, we decided that the Plan does not have to pay for a Positron Emission Tomography (PET) scan 
(78815) provided May 11, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services billed with diagnosis related group 
(DRG) code 199 provided from February 26, 2020, to March 1, 2020. 
 
You asked the Plan to pay for the inpatient hospital services billed with DRG 199. You say that acute 
respiratory failure, with hypoxia is a valid diagnosis. The Plan denied your request. The Plan says that DRG 
199 is not supported as the diagnosis of acute respiratory failure, with hypoxia. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a copy of the applicable medical records for this case. 
Without this information we cannot determine that the Plan's coverage rules support the denial of payment in 
this case. Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we 
decided that the Plan has to pay for the inpatient hospital services billed with diagnosis related group (DRG) 
code 199 provided from February 26, 2020, to March 1, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine received on June 21, 2021. 
 
You asked the Plan to pay for the services. You say that the first dose of this vaccine was covered. The Plan 
denied your request. The Plan says if the service is received in a physician's office, the enrollee must pay the 
provider, and file a reimbursement claim to the Part D plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The 
Plan follows the same rules.  
 Records do not show that you have been injured or directly exposed to any illness related to shingles. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine received on June 21, 2021.  
 
Benefits for the services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341 x 2) 
provided on June 17, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services were necessary. The Plan denied 
your request. The Plan says periodontal scaling and root planing is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal scaling and root planing (D4341 x 2) provided on June 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from January 12, 2021, to January 31, 2021.

You asked the Plan to waive the copayment for the inpatient hospital care. You say that you feel you should not be held responsible for these payments. The Plan denied your request. The Plan says the copayment amount you are being charged 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 $360 copay per day for days 1 to 5 and a $0 copay per day for days 6 to 90 for Inpatient hospital care. 

You have been asked to pay a $360 copay per day for days 1 to 5 and a $0 copay per day for days 6 to 90 for the inpatient hospital care. The 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 copayment for the inpatient hospital care provided from January 12, 2021, to January 31, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) rendered by the 
out-of-network (OON) provider on June 9, 2021. 
 
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 psychiatric diagnostic evaluation (90791) rendered by the out-of-network (OON) 
provider on June 9, 2021.