Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided by an out-of-network provider on April 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) provided by an out-of-network provider 
on April 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 16, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that this service was not related to the patient's 
hospice diagnosis. The Plan denied your request. The Plan says the patient was enrolled in hospice on the date 
of service.  Services unrelated to the hospice diagnosis should be billed to Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99203 billed for date of service May 10, 
2022. 
 
You asked the Plan to pay for procedure code 99203. You say that the patient has not seen another provider in 
the group within the past 3 years. The Plan denied your request. The Plan says this is not the appropriate code 
for this 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, the CPT Code Manual definition of code 99203 is New patient office or other outpatient visit, 30-
44 minutes. Medicare rules also say that in order to use a 'new patient' code, that means a patient who has not 
received any professional services within the previous 3 years.   
We find that CPT code 99203 is not supported in the medical record. Specifically records show that a provided 
with the same provider ID, tax ID, and specialty billed services for this patient in 2020. The other provider in 
the group billed services for this patient on September 3, 2020, and on October 2, 2020. Because of that, this 
patient cannot be considered a new patient for billing purposes. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99203 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99203 billed for date of service May 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on February 17, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that the services provided to the enrollee was 
medically necessary and you would like the claim processed for payment. The Plan denied your request. The 
Plan says the rendering provider is an OON provider and there was no approved authorization. Also, the 
service rendered was not urgent or emergent. 
 
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 health visit provided on February 17, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services on February 28, 2022, 
to April 11, 2022. 
 
You asked the Plan to waive the copayment for outpatient services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing 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 $475 
copayment for Medicare-covered outpatient hospital services. We cover medically-necessary services you get 
in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. Covered services 
include but are not limited to services in an emergency department or outpatient clinic, such as observation 
services or outpatient surgery. The provider billed in the amount of $347 and the allowed amount is $392.60. 
This is less than the copayment amount. There were two visits. $392.60 x 2 = $785.20. Therefore, results in the 
total cost sharing amount of $785.20. 
 You have been asked to pay a $392.60 copayment, which is less than the copayment for outpatient services. 
Outpatient services fall within the Outpatient hospital 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 outpatient services on February 28, 2022, to April 11, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99285 billed for date of service February 2, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that this service was performed twice in one day, 
so the claim denied as a duplicate in error. The Plan denied your request. The Plan says that this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, the medical records appear to document 
two separate emergency evaluation and management services performed on the patient on this same date of 
service.  One occurred at 5:37pm and one visit occurred with a different provider within the group at 10:25pm.  
Based on this information, we decided that Medicare rules for coverage of procedure code 99285 have been 
met. Therefore, we decided that the Plan has to pay for procedure code 99285 billed for date of service 
February 2, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 13, 2022. 
 
You asked the Plan to pay for the medical services. You say that this claim was denied in error. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 24, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the medical services have not been met. 
Therefore, we decided that the Plan does not have to pay for medical services provided on January 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 28, 2021. 
 
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 the services are not supported in the records 
provided. 
 
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 laboratory services provided on 
May 28, 2021, have been met. The submitted medical documentation did not include a lab report or lab results, or a complete description of the not otherwise specified code billed. Therefore, we decided that the Plan does 
not have to pay for the laboratory services provided on May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
March 31, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the provision of F1CDx to the enrollee 
meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that tests not ordered by the physician who is treating the 
beneficiary are not reasonable and necessary. 
 
We looked at the file and Medicare rules. Outreach to the referring provider listed on the claim form and the 
provider advised that they did not write the order for the genetic testing for the enrollee. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) 
provided March 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the hip, and the transport and set up of x-ray 
equipment provided on May 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an x-ray of the hip, and the transport and set up of x-ray equipment. You say that 
you are unable to get authorizations for the patients as once you receive the demographic information, it is too 
late for the authorization as the x-ray has already been taken. The Plan denied your request. The Plan says prior 
authorization must be obtained prior to out-of-network services being rendered. The Plan also says that this was 
not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan 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 an x-ray of the hip, and the transport and set up of 
x-ray equipment provided on May 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 a tympanometry and reflex threshold and comprehensive 
hearing test (92550, 92557) provided on April 27, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the tympanometry and reflex threshold and comprehensive hearing test. You say 
that the services should be covered as you disagree with the denial. The Plan denied your request. The Plan 
says the services denied correctly as they were non-emergent and prior authorization was not obtained. 
 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 tympanometry and reflex threshold and 
comprehensive hearing test (92550, 92557) provided on April 27, 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 the home health visit (99335) provided on December 23, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that your doctors are the only providers who were 
able to treat the patients. The Plan denied your request. The Plan says the services were provided out-of-
network and were not approved in advance. 
  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 the home health visit (99335) provided on 
December 23, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomographic angiography, of the neck, with 
contrast material(s), including non-contrast images, if performed, and image post processing (70498) provided 
on March 3, 2022. 
 
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 this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the service at issue was paid for by 
the Plan on April 6, 2022. A comparison of the two claims shows these are exact duplicates.  There is no evidence presented to support that the billed service was provided twice on the same date. Based on 
this information, we decided that the Medicare rules for coverage of this service have not been met.  
Therefore, we decided that the Plan does not have to pay for the computed tomographic angiography, of the 
neck, with contrast material(s), including non-contrast images, if performed, and image post processing 
(70498) provided on March 3, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided from June 20, 2021, to June 28, 
2021. 
 
You asked the Plan to pay for the hospital services. You say that the enrollee was not enrolled in hospice on the 
date of service. The Plan denied your request. The Plan says original Medicare is responsible for payment. 
 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 hospital services provided from June 20, 2021, to June 28, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on March 9, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that it was the responsibility of the hospital 
staff to obtain authorization. The Plan denied your request. The Plan says the services were provided out-of-
network and were not approved in advance. 
 
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 the nursing facility care provided on March 9, 
2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 2, 2020. 
 
You asked the Plan to pay for the medical services. You say that this claim was billed correctly and is not a 
duplicate. The Plan denied your request. The Plan says you billed with an incorrect POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must enter the correct Place of Service 
(POS) code on the claim. POS 31 is defined as a skilled nursing facility. POS 33 is defined as a custodial care 
facility and POS 61 is a comprehensive inpatient rehabilitation facility.  The facility where the member was 
located at the time of this service was a long-term rehabilitation facility.  It was not a skilled nursing facility, 
and the patient was not in a covered skilled nursing facility stay.  Therefore, POS code 31 is not appropriate in 
this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on March 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on March 21, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the services were not urgent, emergent, or approved in advance. 
 
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 surgical services provided to the enrollee on 
March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 8, 
2022. 
 
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 date of service for a clinical laboratory test or the technical component of physician 
pathology service must be the date the specimen was collected. 
 
The Plan must follow Medicare rules. Medicare rules say that the date of service for clinical laboratory tests 
must be the date that the specimen was collected. 
 
The specimen was collected on February 8, 2022. This date should be considered the date of service for this 
case. 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 laboratory services provided to the enrollee on 
March 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable drug delivery system and supplies (codes 
A4305, A4306, and A9274) provided from March 6, 2022, to March 16, 2022. 
 
You asked the Plan to pay for the disposable drug delivery system and supplies. You say that these items 
should be covered because these home infusion supplies were medically necessary. The Plan denied your 
request. The Plan says these are non-covered items. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, (A4305, 
A4306, A9274) are non-covered devices because they do not meet the Medicare definition of durable medical 
equipment. Drugs and supplies used with disposable drug delivery systems are also non-covered items. We 
looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage 
of the disposable drug delivery system and supplies have not been met. Therefore, we decided that the Plan 
does not have to pay for the disposable drug delivery system and supplies (codes A4305, A4306, and A9274) 
provided from March 6, 2022, to March 16, 2022.