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

 
We decided that the Plan does not have to pay for the dialysis services (90935) and Epoetin alpha injection 
(Q4081) provided on June 20, 2019 to November 21, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the dialysis and injection. You say that the enrollee received hemodialysis to 
sustain his life. This is a free standing outpatient hemodialysis clinic. The enrollee has a history of end stage 
renal disease, anemia and chronic kidney disease. The Plan denied your request. The Plan says enrollee must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 dialysis services (90935) and Epoetin alpha 
injection (Q4081) provided on June 20, 2019 to November 21, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on May 26, 2020, through June 2, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you do not have the 
money for these additional costs. 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 $30 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $30 copayment for a specialist office visit. The correct copayment has been 
applied to the specialist services that were provided. A specialist office visit falls within the 
physician/practitioner services/specialist 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 provided by a participating provider on May 26, 2020, through June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on March 11, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the right to recover for services is not extinguished 
by specific Plan requirements. The Plan denied your request. The Plan says the services were provided by non-
contracted providers 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 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 office visit (99214) provided on March 11, 
2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided to you on February 15, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is 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 February 15, 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 to you on 
February 15, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the allergy testing rendered on October 22, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says 71 units of procedure code 95004 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95004 is percutaneous tests (scratch, puncture, prick) 
with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of 
tests. 
 
We find that CPT code 95004 is not supported in the medical record. Specifically, the submitted allergy report 
does not support the billing of 71 units. 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 pay for the allergy 
testing rendered on October 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the additional intraoral x-ray (D0230) 
provided on January 15, 2020 by the out of network dentist. 
 
You asked the Plan to pay the in network rate for the additional periapical x-ray. You say that you confirmed 
that the dental office was in network. You say that the dentist that was assigned to you was not in network. You 
also say that you had no idea that, that would be the case. The Plan denied your request. The Plan says 1 
intraoral x-ray is covered per calendar year. The Plan says that the frequency limit has been exceeded. 
 
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 and intraoral x-rays are a covered 
service, the frequency limit has been exceeded. The record shows that the Plan paid for the initial intraoral x-
ray that you received on the date of service. Therefore, we decided that the Plan does not have to pay the in 
network rate for the additional intraoral x-ray (D0230) provided on January 15, 2020 by the out of network 
dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abutment supported removable denture for edentulous 
arch (D6111) provided on September 25, 2019. 
 
You asked the Plan to pay for the dental item. You say that you were advised that the dentures would be 
covered. You say that you have coverage for dentures. The Plan denied your request. The Plan says abutment 
supported removable denture for edentulous arch is not listed as 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 abutment supported removable 
denture for edentulous arch is not among those covered under this benefit. The record shows that although you 
did call the Plan, you only inquired about "dentures" and not the specific type of denture or code. Therefore, we 
decided that the Plan does not have to pay for the abutment supported removable denture for edentulous arch 
(D6111) provided on September 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you $100 for the contact lenses you purchased on June 5, 
2019. 
 
You asked the Plan to reimburse you $100 for the contact lenses. You say that you did not realize you had a 
vision benefit. The Plan denied your request. The Plan says you did not have a routine eyewear benefit in 2019. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. You did not have 
a routine eyewear benefit in 2019. Therefore, we decided that the Plan does not have to reimburse you for the 
contact lenses you purchased on June 5, 2019.
Appeal type: Lab
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 May 21, 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 May 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 4, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan.  
 
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 
physician's services. 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 physician's services provided on March 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT Scan of the head or brain (70450) provided on May 6, 
2020. 
 
You asked the Plan to pay for the CT Scan. You say that you would like reconsideration because the services 
rendered were medically necessary. The Plan denied your request. The Plan says this claim was billed with 
place of service code 22 (outpatient), but the member's claim history indicates they were inpatient during this 
date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, 
shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient 
actually receives the face-to-face encounter. 
 
We find that CPT code 70450 is not supported in the record. Specifically, the record indicates that this member 
was registered inpatient on the billed date of service. It is inappropriate to bill this claim with an outpatient 
place of service code. Based on this information, we decided that Medicare rules for coverage of the CT Scan 
have not been met. Therefore, we decided that the Plan does not have to pay for CT Scan of the head or brain 
(70450) provided on May 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the positron emission tomography (PET) scan rendered on 
February 6, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the diagnosis is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee underwent a PET/CT from 
skull base to mid-thigh for an indication of "restaging unknown primary squamous cell carcinoma. Subsequent 
treatment strategy." There are no clinical records for review. There are no medical records in the case file that 
support the billing of diagnosis C44.92 (other and unspecified malignant neoplasm of skin) as reasonable and 
medically necessary. 
 
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 pay for the positron emission tomography (PET) scan rendered on February 6, 2020.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for air ambulance services provided on March 30, 2020. 
 
You asked the Plan to pay for the air ambulance services. You say that the attached flight records support the 
need for the services in dispute, which were emergent and provided in good faith. The Plan denied your 
request. The Plan says that air ambulance services were not medically necessary. The Plan says that the 
enrollee could have been safely transported by basic life support ground ambulance or another type of motor 
vehicle. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the criteria for coverage have been met. Our physician reviewer found it was medically appropriate 
for this enrollee to be transported to the outside facility with access to GI consultation and evaluation for an 
acute GI bleed. This needed to be done emergently given the enrollee's symptom of syncope in the setting of 
low hemoglobin and hematocrit. Therefore air ambulance would be most appropriate given noted travel time of 
25 minutes via air versus 70 minutes by land. 
 
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 air ambulance services have been met. Therefore, we decided that the Plan 
has to pay for air ambulance services provided on March 30, 2020.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 11, 2020. 
 
You asked the Plan to pay for the laboratory services. 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 
laboratory services. 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 laboratory services provided on February 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 16, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
laboratory services. 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 laboratory services provided on March 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis (L1851), suspension sleeve (L2397) and 
straight knee joint (L2385) provided on April 5, 2020. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like reconsideration 
because the supplies are medically necessary. The Plan denied your request. The Plan says the documentation 
submitted did not include an itemized shipping/billing invoice to indicate the specific supplies or proof of 
delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
record does not include an itemized billing/shipping invoice to verify the billed supplies. Additionally, the 
documentation submitted does not include proof of delivery for the billed date of service. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for knee orthosis (L1851), suspension sleeve (L2397) and straight 
knee joint (L2385) provided on April 5, 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. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee has a history of stroke with persistent left 
hemiplegia. He is living at home and receiving physical therapy. He is becoming weaker and needs more help 
at home. Medical problems are stable. There are no identified problems that need inpatient medical 
management. There are no complex nursing or rehabilitation needs. 
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not 
a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit services provided to the enrollee from January 13, 
2020 to January 19, 2020. 
 
You asked the Plan to pay for the services. You say that you are out-of-network but Medicare-certified. The 
Plan denied your request. The Plan says you are a privately contracted 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 
office visit services provided to the enrollee from January 13, 2020 to January 19, 2020.