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

 
We decided that the Plan does not have to pay for the diagnostic digital breast tomosynthesis services coded 
77062 provided on 
 
You asked the Plan to pay for the diagnostic digital breast tomosynthesis 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 
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, the CPT Code Manual definition of code 77062 is diagnostic digital breast tomosynthesis; 
bilateral. 
 
We find that CPT code 77062 is not supported in the medical record. Specifically, this code has a status code of 
"I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for 
reporting of, and payment of these services. Based on this information, we decided that Medicare rules for 
coverage of the diagnostic digital breast tomosynthesis services have not been met. Therefore, we decided that 
the Plan does not have to pay for the diagnostic digital breast tomosynthesis services coded 77062 provided on
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gradient compression stockings (CPT Code A6530). 
 
You asked the Plan to pre-approve the compression stockings. You say that the provider has prescribed 
compression socks as a method of therapy to relieve pain from your ankle. The Plan denied your request. The 
Plan says this is not covered by Medicare. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the compression stockings have not been met. The specific gradient 
compression stockings that your physician ordered are not covered for any reason because they do not meet the 
definition of a surgical dressing. There is also no documentation that you are being treated for a venous stasis 
ulcer. Therefore, these stockings are not covered by your Plan. Therefore, we decided that the Plan does not 
have to pre-approve gradient compression stockings (CPT Code A6530).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard provided on July 20, 2020. 
 
You asked the Plan to pay for the occlusal guard. You say that you have celiac disease, and in order to avoid 
further erosion of enamel, a night guard was recommended. The Plan denied your request. The Plan says this is 
not 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 
occlusal guard provided on July 20, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer 
found the patient does not require skilled nursing services with the specialized skill, knowledge and judgment 
of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable 
treatment in a SNF. The patient does not have complex wound care or other ongoing SNF level SN need. The 
patient does not require breathing treatments, supplemental oxygen, and has remained afebrile and 
hemodynamically stable. The patient did not need SN for vital sign monitoring. The patient does not require 
skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require 
skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a 
practical matter, this patient does not require the necessary services on an inpatient basis, in a SNF setting.  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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral evaluation (D0120), prophylaxis (D1110), and 
bitewing x-rays (D0274) provided on July 22, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services were denied as "out of network". 
You say that you had similar work done earlier this year by the same provider. You say that the claim was paid. 
The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also 
says that payment cannot be made for services that you receive from a provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the oral 
evaluation (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on July 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on June 18, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services 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 has network providers 
available who can provide 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 medical services provided to you by an out-of-network provider on June 
18, 2020.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is no documentation that the patient requires the 
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility as his medical 
conditions are all stable and his rehabilitation needs are not complex. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the stress test provided on September 8, 
2020. 
 
You asked the Plan to waive the copayment for the stress test. You say that the stress test should be included in 
your office visit copayment of $45. The Plan denied your request. The Plan says the claim was processed 
accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received the stress test provided on September 8, 2020. You are asked to pay a 
$10 copayment for the stress test and a $45 copayment for the specialist office services. Your EOC states, 
"when you receive outpatient services, the cost sharing listed below in this Medical Benefits Chart generally 
applies to each service you receive, including multiple services from the same provider, or multiple claims 
related to the same service. For example, if you have an office visit and your doctor requests diagnostic lab 
work and radiology services, cost sharing may apply to each service. If you have outpatient surgery, cost 
sharing may apply to the facility charge and the physician charge." 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 stress test provided on September 8, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ANORO ELLIPTA Aer 62.5-25 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary The Plan denied your 
request. The Plan says this is denied as a benefit exclusion. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve ANORO ELLIPTA Aer 
62.5-25
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on August 11, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that this was an injection. You 
say that you feel like this being billed as an outpatient surgery is a mistake. The Plan denied your request. The 
Plan says the correct copayment has been applied. 
 
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 $300 
copayment for outpatient surgery.  
 
You have been asked to pay a $300 copayment for an outpatient surgery. The injection you had is considered 
an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls within the 
outpatient surgery 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 an outpatient surgery 
provided by a participating provider on August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on August 11, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 has network providers 
available who can provide 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 medical services provided to the enrollee by an out-of-network provider 
on August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on August 14, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 has network providers 
available who can provide 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 medical services provided to the enrollee by an out-of-network provider 
on August 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on May 
11, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you could have gotten a 
ride but the hospital said you needed to be transported by ambulance. 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 a $225 
copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $225 for these 
services. 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 ambulance services provided on May 11, 
2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department visit for the evaluation and 
management of a patient (CPT Code 99284) provided on July 3, 2020. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services were previously approved/paid to this provider and there is no additional 
documentation supporting additional services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Based on this information, we decided that Medicare rules for coverage of the service have not been met. The 
member was seen in the emergency room on July 3, 2020. The submitted documentation supports one (1) unit 
each of 99284 and 99283, which were previously approved/paid to this provider. There is no additional 
documentation supporting additional services which were billed and remain denied. Therefore, we decided that 
the Plan does not have to pay for emergency department visit for the evaluation and management of a patient 
(CPT Code 99284) provided on July 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies received on August 28, 2020. 
 
You asked the Plan to pay for incontinence supplies. You say that the provider ordered these supplies and 
should be responsible for the payment. The Plan denied your request. The Plan says these items do not meet the 
requirements for approval. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies received on 
August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99204) provided on March 10, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says only one unit of this 
service is supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met.  
 
We looked at the file and Medicare rules. The documentation shows that one unit of CPT 99204 was provided 
on the date of service in question. The Plan paid for one unit of CPT 99204. Additional units of CPT 99204 are 
not supported. 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 the services (CPT 99204) provided on 
March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services (HCPCS J7050 and S0077) provided to the 
enrollee on July 20, 2020. 
 
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 these are invalid procedure codes for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
HCPCS J7050: 
 
Infusion, normal saline solution, 250 cc 
 
HCPCS S0077: 
 
Injection, clindamycin phosphate, 300 mg 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
administered clindamycin should be billed with a drug injection code and a drug code, not an S code. The 
normal saline should be billed with a normal saline irrigation code, not a normal saline infusion code. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for injection services (HCPCS J7050 and S0077) provided to the enrollee on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve podiatry services. You say that you have been seeing this provider for about 
8 to 10 years and do not feel comfortable seeing another podiatrist. The Plan denied your request. The Plan 
says the denial of authorization for these services is correct, because this provider is out-of-network with the 
Plan and you can be treated by an in-network podiatrist. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a panniculectomy for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested surgery is for the primary intent to improve appearance. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is a 56-year-old woman with Localized adiposity. On 9/1/20 it is documented that the 
enrollee has a pannus, with chronic skin changes, rubor and hyperpigmentation. It is noted that "The physical 
exam is within the range of normal. The enrollee does not have a significant pannus and does not qualify for 
panniculectomy or other body contouring procedure such as abdominoplasty due to a normal physical exam of 
those structures." 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a panniculectomy for the enrollee.