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

 
We decided that the Plan does not have to pay for surgical services (procedure code 64415) provided to the 
enrollee on May 28, 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 surgical services (procedure code 64415) provided to the enrollee on May 28, 2021. 
 
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 64415 is "Injection(s), anesthetic agent(s) and/or steroid; 
brachial plexus." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the documentation includes a Provider 
Remittance Advice for CPT 64415 with a date of service of May 28, 2021. However, the peripheral nerve 
blockage documents a June 4, 2021 date of service. Confirmation cannot be made for this service, and a query 
would be made before billing services.  
We looked at this coder's review, the file, and Medicare rules. 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 surgical services (procedure code 64415) provided to the enrollee on May 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a queen tempur-ergo extend smart adjustable bed power 
base, with massage (A9270). 
 
You asked the Plan to pay for a queen tempur-ergo extend smart adjustable bed power base, with massage. You 
say that the item should be covered. The Plan denied your request. The Plan says you purchased the bed on 
ebay, which is not a Medicare approved supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a queen tempur-ergo extend smart adjustable bed 
power base, with massage (A9270).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urology visit you had on September 16, 
2021. 
 
You asked the Plan to waive the copayment for the urology visit. You say that you believe you had met your 
maximum out of pocket (MOOP) for the year, so you should not have a copayment. The Plan denied your 
request. The Plan says one of the claims processed during the year (for a specialist visit you had on February 
26, 2021), was backed out and no copayment was charged for that service.  Because of no copayment was 
charged for this date, you still had $30 remaining before your hit your MOOP at the time the claim for the 
September 16, 2021 date of service was received.  Therefore, you were charged this copayment 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 $30 
copayment for visits with a specialist.  
 
You have been asked to pay a $30 copayment for the urology visit. The Plan has confirmed that due to a 
backed-out claim, you had not met your MOOP at the time the claim for the urology visit was processed. 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 urology visit you had on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on August 2, 2021. 
 
You asked the Plan to waive the deductible for an office visit. You say that there should be no copayment for 
an office visit. The Plan denied your request. The Plan says the enrollee did not meet their deductible prior to 
the date of service. The proper cost share was applied for this service. 
  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 $198 
deductible this is the amount you have to pay out-of-pocket before we will pay our share for your covered 
medical services. Until you have paid the deductible amount, you must pay the full cost of your covered 
services. Once you have paid your deductible, we will begin to pay our share of the costs for covered medical 
services and you will pay your copayment or coinsurance amount for the rest of the calendar year. Prior to the 
date of service, the enrollee had paid $119.51 towards the $198 total deductible amount. The deductible amount 
charged for the date of service was $78.49 which met the yearly deductible amount of $198 ($119.51 
deductible paid prior + $78.49 deductible charged. 
 
You have been asked to pay a $78.49 deductible for an office visit. The deductible for the office visit falls 
within the What is your plan deductible 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 deductible 
for an office visit provided on August 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing (81479) provided on June 29, 2021. 
 
You asked the Plan to pay for Guardant360 testing. You say that this was billed correctly. The Plan denied your 
request. The Plan says this was not billed with the correct place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Guardant360 testing have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the member's face-to-face service was rendered in a laboratory setting. 
Therefore, we decided that the Plan does not have to pay for Guardant360 testing (81479) provided on June 29, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428-HR), ground mileage (A0425-HR, -RH), and ambulance service, advanced life support, 
emergency transport (A0427-RH) provided on October 5, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the ambulance services were medically 
necessary. The Plan denied your request. The Plan says the services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ambulance services. Our reviewer says 
that the ambulance services were not medically necessary. Our physician reviewer found that the 
documentation supports that other means of transport (such as stretcher van, wheelchair van, taxi, private car, 
or other type of vehicle) were not contraindicated for this patient on October 5, 2021.  
 The reviewer found that the documentation did not support that the patient needed the expertise, services and 
lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. 
The reviewer also found that the documentation did not support that the ambulance transport on October 5, 
2021, was medically reasonable and necessary for the enrollee. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428-HR), 
ground mileage (A0425-HR, -RH), and ambulance service, advanced life support, emergency transport 
(A0427-RH) provided on October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extractions (D7210), alveoloplasty (D7311), 
panoramic x-ray (D0330) and immediate upper denture (D5130) provided on June 22, 2021, the denture 
services (D5611, D5650) provided on July 15, 2021, and the extractions (D7140, D7210) provided on August 
24, 2021. 
 
 
 
 You asked the Plan to pay for the dental services. You say that this provider is in-network, and you feel you 
received this bill in error. You cannot afford these services and do not understand why these claims are not 
being paid. The Plan denied your request. The Plan says while extractions are a covered service, you are 
limited to two extractions per calendar year. You received two extractions on April 20, 2021, which were 
covered at that time. The additional extractions in this case exceeded the limitations of your benefit and will not 
be covered. The remaining services are not covered under your dental benefit. 
 
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 or are requested in a frequency that exceeds what is covered by this 
benefit. Therefore, we decided that the Plan does not have to pay for the surgical extractions (D7210), 
alveoloplasty (D7311), panoramic x-ray (D0330) and immediate upper denture (D5130) provided on June 22, 
2021, the denture services (D5611, D5650) provided on July 15, 2021, and the extractions (D7140, D7210) 
provided on August 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you need these services to regain strength and 
make yourself more mobile. The Plan denied your request. The Plan says that the services you require can 
safely be received at a different setting. 
 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services 
(90792) rendered by the out-of-network (OON) provider on July 21, 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 psychiatric diagnostic evaluation with medical services (90792) rendered by 
the out-of-network (OON) provider on July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 27, 2021. 
 
You asked the Plan to pay for the lab services. You say that this is a covered lab service separate and distinct 
from the patient's hospital services. The Plan denied your request. The Plan says you provided the incorrect 
Place of Service code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that that if an independent lab bills for services, the 
place where the sample was taken is reported as the Place of Service (POS). An independent laboratory taking 
a sample in its laboratory shows "81" as place of service. In this case, you have billed with a POS of 81, but the 
records do not indicate that your lab physically took the specimen from the enrollee.  Rather, it appears as 
though the specimen was taken from the enrollee at another location and the specimen was sent to you. In such 
cases, POS 81 should not be used on the claim.  
We looked at the file and Medicare rules. 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 provided on July 27, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department visit provided September 6, 2021. 
 
You asked the Plan to pay for the emergency visit. You say that per EMTALA guidelines, patients have to be 
treated and stabilized regardless of insurance and payer are supposed to cover ER service wither in network or 
not. The Plan denied your request. The Plan says that interim rate letter needed for payment. 
 
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 is citing Rural Health Clinics/Federally Qualified Health centers rules 
to a General Acute Hospital and has not substantiated their reason to continue to deny. Therefore, we decided 
that the Plan has to pay for the emergency department visit provided September 6, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on June 29, 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 the denied codes remain 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 the denied codes is: 
 
CPT 11043: 
 
Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 
sq cm or less 
 
CPT 11046: 
 
Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each 
additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) 
 
CPT 15002: 
 
Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including 
subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body 
area of infants and children 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found after careful research of CMS 
guidelines, no guideline was found to support surgical debridement cannot be performed in the home setting 
with a regional anesthetic. However, modifier 59 is not supported for CPT 11043, as there is no other 
procedure performed that this procedure would be separate from. For CPT 11046, as the documentation does 
not support CPT 11043, it also does not support CPT 11046, as this is an add-on code. If the primary code is 
denied an add on code would not be covered. Also, the documentation does not support 9 additional units. In 
terms of CPT 15002, the procedure report does not document surgical preparation or recipient site by excision 
of open wounds. 
 
We looked at this coder's review, the file, and Medicare rules. 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 surgical services provided to the enrollee on June 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from December 1, 2016, to January 4, 2017. 
 
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 provider has reported skilled services with the incorrect RUG Health Insurance Prospective 
Payment System (HIPPS) Score. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. 
 
We find that the denied skilled nursing services are not supported in the medical record. Specifically, the 
provider did not send a completed 5 day or admission Minimum Data Set (MDS) assessment. This is needed to 
determine if the correct score was used. 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 skilled nursing 
facility (SNF) services provided to the enrollee from December 1, 2016, to January 4, 2017.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee would 
have difficulty tolerating 3 hours of therapy a day. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our physician reviewer found 
that the enrollee suffered a right hip fracture in a fall. Postoperatively she developed anemia and acute kidney 
injury. Her balance is fair. She is limited due to pain. The complexity of her nursing, medical and rehabilitation 
needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
At this time, there is not a reasonable expectation that she will be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an IRF. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the LifeVest you rented from September 
21, 2020, to December 21, 2020. 
 
You asked the Plan to waive the coinsurance for the LifeVest. You say that you cannot afford this coinsurance. 
The Plan denied your request. The Plan says you were charged this coinsurance 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 durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the LifeVest. The LifeVest falls within the durable medical 
equipment 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 LifeVest you rented from September 21, 2020, to 
December 21, 2020.