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

 
We decided that the Plan does not have to pay for the consultation provided on July 3, 2020. 
 
You asked the Plan to pay for the consultation. You say that you had a cracked tooth, and the provider took x-
rays. You also say that you know you have coverage for x-rays. The Plan denied your request. The Plan says 
they confirmed with the provider's office that no x-rays were taken during this visit, and only a consultation 
was provided. The Plan also says that consultations are not covered under your plan. 
 
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 
consultation provided on July 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vision care provided on May 18, 2020. 
 
You asked the Plan to waive the copayment for vision care. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for vision services.  
 
The medical records show that you received vision services on May 18, 2020. Therefore, you are responsible to 
pay the $40 copayment.  
 
You have been asked to pay a $40 copayment for vision care. Vision care falls within the vision 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 vision care provided on May 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on August 21, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the member's primary care physician did not refer these services. The Plan says that the referring 
provider is also out-of-network. 
 
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 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 physician services provided on August 21, 2019 
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 office visit for new patient (99203), destruction of 
premalignant lesions 2-14 skin growths (17003) and destruction of premalignant lesion first (17000) provided 
on May 18, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for new office visit and destruction of skin growths. You say that you were provided 
a referral to a non-contracted Dermatology provider. The Plan denied your request. The Plan says prior 
authorization is required. 
 
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 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 office visit for new patient (99203), 
destruction of premalignant lesions 2-14 skin growths (17003) and destruction of premalignant lesion first 
(17000) provided on May 18, 2020, by an out of network (OON) provider.
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 care is not complex enough and does not show it would cause 
excessive physical hardship for the patient to receive needed care in an outpatient basis or SNF. 
 
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 
patient is medically stable with decreased function. He needs physical therapy and occupational therapy but 
will not be able to tolerate the intensity of IRF therapies. The documentation does not support that there is a 
need for an intensive therapy program with 3 hours a day and an interdisciplinary approach to rehab care. 
The enrollee does not meet the CMS coverage criteria for an IRF admission due to lack of ability to tolerate 
therapies. The enrollee's rehab needs can be met in an alternate, less intense setting. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, bone replacement graft for ridge preservation, 
collection and application of autologous blood concentrate product, and subsequent 15 minute increment of 
deep sedation/general anesthesia provided on April 29, 2020. 
 
You asked the Plan to pay for the extraction, bone replacement graft, collection and application of autologous 
blood concentrate product, and deep sedation/general anesthesia. You say that this was the only dentist 
available during the pandemic that could perform these services. You also say that your provider was shut 
down. The Plan denied your request. The Plan says these services were rendered by a Medicare opt out 
provider. The Plan also says that you are responsible for services provided by privately contracted providers. 
 
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. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the extraction, bone replacement graft for ridge preservation, collection and application of autologous blood 
concentrate product, and subsequent 15 minute increment of deep sedation/general anesthesia provided on 
April 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluid flow liquid allograft. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says it is not 
being furnished according to current accepted standards of practice, and has not been proven to be effective. 
 
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 requested services. Our physician 
reviewer found that the enrollee has osteoarthritis of the knee. The requested service is an experimental/ 
investigational placental medication. Therefore, the request is not medically necessary or reasonable. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve fluid flow liquid allograft.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 73110, 73090, and 73130 and the 
application of short arm splint services coded 29125 provided on February 24, 2020. 
 
You asked the Plan to pay for the x-ray services and the application of short arm splint 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. 
 
We find that CPT codes 73110, 73090, 73130, 29125 are not supported in the medical record. Specifically, the 
charge exceeds the fee schedule/maximum allowable or contracted/legislated fee arrangement. Based on this 
information, we decided that Medicare rules for coverage of the x-ray services and the application of short arm 
splint services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray 
services coded 73110, 73090, and 73130 and the application of short arm splint services coded 29125 provided 
on February 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, expandable controller harness, 
electronic connection and a power seat elevation feature for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these items are medically necessary. The Plan 
denied your request. The Plan says that the notes do not show a medical need to control the power options 
through the joystick. 
 
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 an expandable controller, expandable 
controller harness and electronic connection. Our reviewer says that an expandable controller, expandable 
controller harness and electronic connection are not considered medically reasonable and necessary in this case. 
The documentation does not reveal that the patient requires other types of proportional input devices or non-
 
 
proportional input devices. The patient does not need to operate 3 or more powered seating actuators through 
the drive control, a separate display, other electronic devices, or an attendant control. The patient's functional 
ability is sufficient to allow her to control any power options through their own individual switches. Our 
physician reviewer found the enrollee's condition does not meet Medicare criteria for an expandable controller, 
expandable controller harness and electronic connection. 
 
Medicare rules also say that a power seat elevation feature is non-covered because it is not primarily medical in 
nature. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve an expandable controller, expandable controller harness, electronic connection and a 
power seat elevation feature for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99266) provided June 22, 2019. 
 
You asked the Plan to pay for the subsequent hospital care. You say that CPT 36558 has now been voided and 
recovered by the Plan. Please reprocess this claim, now that CPT 36558 has been recovered. The Plan denied 
your request. The Plan says this service is bundled as part of the global surgical fee because it was reported 
within 10 days of the minor surgical procedure 36558 for date of service 6/21/2019 billed by the same 
physician. 
 
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 
subsequent hospital care has a bundled relationship with code 36558 and cannot be paid as billed. This code 
cannot be paid as a separate line item. 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 subsequent hospital care (99266) 
provided June 22, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a nasopharyngoscopy (92511) performed 
on May 21, 2020. 
 
You asked the Plan to waive the coinsurance for a nasopharyngoscopy. You say that the procedure was 
unnecessary. The Plan denied your request. The Plan says the correct coinsurance was 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 20% 
coinsurance for diagnostic procedures and tests.  
 
You have been asked to pay $21.11, or 20% coinsurance of the Plan-allowed amount of $105.54, for a 
nasopharyngoscopy. A nasopharyngoscopy falls within the "Outpatient diagnostic tests and therapeutic services 
and supplies" 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 a nasopharyngoscopy 
(92511) performed on May 21, 2020.  
 
The Qualified Independent Contractor (QIC) read your letter and knows that you may have a quality of care concern. The Qualified Independent Contractor (QIC) cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis, periodontal maintenance, and application of 
desensitizing medicament provided on February 20, 2020. 
 
You asked the Plan to pay for the prophylaxis, periodontal maintenance, and application of desensitizing 
medicament. You say that at the beginning of the year you were told that this treating provider was a 
participating provider. The Plan denied your request. The Plan says these services were rendered by a Medicare 
opt out provider. 
 
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. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the prophylaxis, periodontal maintenance, and application of desensitizing medicament provided on February 
20, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided  on May 29, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 29, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating 
provider on May 11, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that this ultrasound was ordered by a 
nurse. You say that the test wasn't even necessary. 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 $160 
copayment for outpatient diagnostic tests/radiological diagnostic services.  
 
You have been asked to pay $126.21 which is less than your copayment amount of $160 for an ultrasound. 
Since an ultrasound was provided, the correct copayment has been applied. An ultrasound falls within the 
outpatient diagnostic tests/radiological diagnostic 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 an ultrasound provided by a participating provider on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on September 19, 2019.

You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.

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 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 a domiciliary, rest home visit provided on September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) on June 24, 
2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were told by a 
representative of the Plan that your specialist copayment was cancelled until the end of June. The Plan denied 
your request. The Plan says the correct copayment was 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 $50 
copayment for each Medicare-covered visit with a specialist.  
 
You have been asked to pay a $50 copayment for a specialist office visit. A specialist office visit falls within 
the "Physician/Practitioner services, including doctor?s office visits" 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 a specialist office visit (99213) on June 24, 2020.  
 
Your complaint about receiving erroneous or misleading information regarding cost-sharing from a 
representative of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance 
that must be answered by the Plan. Medicare does not permit us to make a decision about these types of 
complaints.