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

 
We decided that the Plan does not have to pay for an x-ray and physician services provided on April 3, 2020, 
by an out of network (OON) provider. 
 
You asked the Plan to pay for an x-ray and physician services. You say that this was a follow-up visit for an 
injury that occurred two weeks prior. 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 
these services could have been provided in-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 an x-ray and physician services provided on April 
3, 2020, by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 27, 2020. 
 
You asked the Plan to pay for the physician service. The Plan denied your request. The Plan says the Medicare 
hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to 
the date of discharge or revocation. The Plan also says that during the election, fee-for-service Medicare also 
covers attending physician services and all care unrelated to the terminal illness until the first day of the month 
following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 1, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the office visit provided on 
May 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT colonography. 
 
You asked the Plan to pre-approve the CT colonography. You say that you would like reconsideration because 
this service is medically necessary. The Plan denied your request. The Plan says this type of study is not 
supported for screening purposes. 
 
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 CT colonography. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was orderd the computed tomography study as the colonoscopy was non-
productive due to incomplete prep. 
 
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 CT colonography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CT colonography.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the cost sharing amount for the limited oral evaluation (D0140), 
the periapical x-ray (D0220), the filling (D2150), the periodic oral evaluation (D0120), prophylaxis (D1110) 
and the fluoride treatment (D1208) provided from March 30, 2020, to May 29, 2020 by the out of network 
dentist. 
 
You asked the Plan to pay the cost sharing amount for the dental services. You say that you have secondary 
insurance. You also say that you should not owe anything. The Plan denied your request. The Plan says the 
claims were processed correctly according to your dental benefits. The Plan says that service provided out of 
network are paid according to a maximum allowable fee schedule and you are responsible for all the fees in 
excess of this amount from the billed amount. 
 
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, dental services that are provided out of 
network have a higher cost sharing amount.  


CPT Code Billed Allowed Primary Ins Paid OON Cost Share Your responsibility 
D0140 $60 $34 $45.90 $0 $14.10 $14.10 
D0220 $20 $11 $12 $0 $8 $8 
D2150 $145 $67 $60.50 $6.50 $78 $78 
D120 $35 $20 $29.75 $0 $5.25 $5.25 
D1110 $78 $43 $55.25 $0 $22.75 $22.75 
D1208 $30 $16 $0 $16 $14 $14 
TOTAL:      $142.10 
 
Therefore, we decided that the Plan does not have to pay the cost sharing amount for the limited oral evaluation 
(D0140), the periapical x-ray (D0220), the filling (D2150), the periodic oral evaluation (D0120), prophylaxis 
(D1110) and the fluoride treatment (D1208) provided from March 30, 2020, to May 29, 2020 by the out of 
network dentist.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on June 25, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated on an emergency basis. 
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 June 25, 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 June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to the enrollee from October 13, 2018, 
to February 25, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says supporting 
documentation was not submitted. 
 
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 submitted documentation does not contain medical records from 
the international provider. Without records, it cannot be determined that the requested services were necessary 
and that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay 
for the services provided to the enrollee from October 13, 2018, to February 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the documentation does not support that 
Zoledronic acid would likely be less effective, and/or would likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
January 8, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network physician services provided to the enrollee on 
January 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650), knee orthosis (L1851) and a 
lower extremity addition (L2397) provided on May 14, 2020. 
 
You asked the Plan to pay for the orthoses. You say that you would like reconsideration because this equipment 
is medically necessary. The Plan denied your request. The Plan says a review of the submitted documentation 
does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required 
per CMS guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
 
 
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis 
(L0650), knee orthosis (L1851) and a lower extremity addition (L2397) provided on May 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept Procedure (22899, C9752). 
 
You asked the Plan to pre-approve the procedure. You say that the procedure is medically necessary. The Plan 
denied your request. The Plan says this procedure is still considered investigational in this application. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure remains experimental for the treatment of low back pain. More research 
is needed to show safety and efficacy. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept Procedure (22899, C9752).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99285) provided on January 
25, 2020. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration 
because this service was billed correctly. The Plan denied your request. The Plan says the level of service for 
this Evaluation and Management code was reduced based on the diagnostic information on the claim. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 
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 emergency department visit. Our reviewer says that CPT 
code 99285 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical 
records do not include sufficient information to validate that the emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status was performed. 

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 emergency department visit have not been met. Therefore, we decided that 
the Plan does not have to pay for the emergency department visit (99285) provided on January 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF 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 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. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You continue to 
have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement 
however, the documentation doesn?t support that you would meet criteria for admission to an acute inpatient 
rehabilitation facility. There is no indication that you would require skilled rehabilitation in an IRF, 
participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain your functional status. You are ambulating up to 500 feet with supervision. You 
are near your prior level of function and could receive services at a lower level of 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 IRF admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health care provided from June 3, 2019 to 
December 24, 2019 by an out of network provider. 
 
You asked the Plan to pay for these services. You say that this treatment should be covered by the Plan. The 
Plan denied your request. The Plan says you self-referred out of network 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 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 outpatient mental health care provided from June 3, 2019 to 
December 24, 2019 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening testing provided on February 20, 2020. 
 
You asked the Plan to pay for laboratory tests. You say that this testing was an extension of an examination at 
the referring physician's office and you do not have information on the enrollee's insurance requirements, 
limitations, or conditions. The Plan denied your request. The Plan says the denial of payment for these services 
is correct, because these tests are not a Medicare benefit for the diagnoses listed and were performed for 
screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, laboratory tests, were requested solely for screening purposes. Medicare does 
not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
screening testing provided on February 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits (97110, 97140, 
and/or 97530) on March 24 to May 28, 2020. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you were informed by a 
representative of the provider that you had a $0 copayment. 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 $20 
copayment for Medicare-covered Physical Therapy visits.  
 
You have been asked to pay $420, or a $20 copayment for 21 physical therapy visits. Physical therapy visits 
fall within the "Outpatient rehabilitation 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 physical therapy visits (97110, 97140, and/or 97530) on March 24 to May 28, 2020.  
 
Your complaint about receiving erroneous or misleading information from a representative of the provider 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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI scan of the thoracic spinal canal 
(72146) performed on July 22, 2019. 
 
You asked the Plan to waive the copayment for an MRI scan of the thoracic spinal canal. You say that the 
performed services were of no benefit to your circumstances. 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 $225 
copayment for each Medicare-covered advanced imaging service (not including X-rays).  
 
You have been asked to pay a $202.92 copayment for an MRI scan of the thoracic spinal canal. An MRI scan 
of the thoracic spinal canal falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 
benefit category. This means that you have been asked to pay less than the full 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 MRI scan of the thoracic 
spinal canal (72146) performed on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam provided on February 24, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for an eye exam. You say that your staff was never notified that prior authorization 
was needed. The Plan denied your request. The Plan says 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 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 an eye exam provided on February 24, 2020 by an 
out of network (OON) provider.