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

 
We decided that the Plan does not have to pay for a vaccination provided on June 8, 2020. 
 
You asked the Plan to pay for the vaccination. The Plan denied your request. The Plan says that, in most cases, 
the care you receive from an out-of-network provider will not be covered. If you need medical care that 
Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this 
care from an out-of-network provider. You, or your PCP, must obtain authorization from the Plan prior to 
seeking 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
service 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 vaccination provided on June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on June 21, 2019. 
 
You asked the Plan to pay for an office visit. You say that this was filed timely. The Plan denied your request. 
The Plan says this claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for an office visit was not filed until July 17, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for an office visit (99214) provided on June 21, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided 
on September 3, 2020. 
 
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you disagree 
with the charges because you met the MOOP amount for the year. 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 the 
MOOP amount for 2020 is $2,800. Your contract with the Plan also clearly says that you must pay a $40 
copayment for outpatient rehabilitation services. 
 
You received outpatient rehabilitation services on September 3, 2020. The record shows that you had only paid 
$2,521.85 toward the $2,800 MOOP amount.  Therefore, you are responsible to pay the $40 copayment for 
outpatient rehabilitation services.  
 
You have been asked to pay a $40 copayment for outpatient rehabilitation services. Outpatient rehabilitation 
services 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 outpatient rehabilitation services provided on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit (99214) provided on 
September 2, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that you should not have to pay the 
copayment. The Plan denied your request. The Plan says the copayment was applied 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 $20 
copayment for urgently needed services.  
 
You have been asked to pay a $20 copayment for an office visit. An office visit falls within the urgently needed 
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 office visit (99214) 
provided on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided on August 27, 2020, by an out-
of-network provider. 
 
You asked the Plan to pay for the vision services. You say that the facility was responsible for obtaining 
authorization therefore it is imperative that the Plan reimburse the doctor. The Plan denied your request. The 
Plan says you did not request 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 had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 
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 vision services provided on August 27, 2020, by an out-of-network 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extracapsular cataract removal with insertion of 
intraocular lens prosthesis (66984) provided August 19, 2020. 
 
You asked the Plan to pay for the cataract surgery. You say that you feel that you should not be responsible for 
this claim and as of 10/06/2020 you have terminated the primary payer. The Plan denied your request. The Plan 
says the primary insurance must process the claim first. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan is the enrollee's 
secondary insurance. As the secondary insurer, the Plan cannot be held responsible for the cataract surgery 
until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not 
have to pay for the extracapsular cataract removal with insertion of intraocular lens prosthesis (66984) provided 
August 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance services and ground mileage 
(A0425, A0428) provided on August 13, 2020. 
 
You asked the Plan to pay for the non-emergency ambulance services and ground mileage. You say that you 
would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says 
ambulance transport to or from an outpatient office is not a Medicare covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor?s office is not a covered destination.  
 
The services you have asked the Plan to waive the copayment for are ambulance transport services to a doctor?s 
office. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance services and 
ground mileage (A0425, A0428) provided on August 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81551) provided August 10, 2020. 
 
You asked the Plan to pay for the genetic testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says the test does not meet coverage rules as the enrollee previously had the 
same test performed. 
 
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx is covered when the patient has not 
been previously tested by ConfirmMDx.  
 
We looked at the file and Medicare rules. The record shows a previous biopsy where the enrollee was tested by 
ConfirmMDx. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81551) 
provided August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the periodontal scaling and root planing (D4342 x 2) provided on 
August 3, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services were done together due to Covid-19 
protocols. You say that it was safer for the staff and you to do both procedures together rather than at 2 separate 
times and risking more exposure. The Plan denied your request. The Plan says that there is a benefit limitation 
of 1 periodontal scaling and root planing per day. The Plan also says that the benefit limitation has been 
exceeded. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms which services are covered. The Plan 
contract does not say in clear and accurate terms the situations in which dental services would not be covered.  
 
We looked at your contract with the Plan. We did not see where the contract says that periodontal scaling and 
root planing is covered once per day. The Plan contract does not clearly state the situations in which 
periodontal scaling and root planing is not covered. This means that the Plan did not follow Medicare rules for 
disclosure of cost sharing information. Therefore, we decided that the Plan has to pay for the periodontal 
scaling and root planing (D4342 x 2) provided on August 3, 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: 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 6, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available 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 had network providers 
available who could have provided 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 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for myocardial perfusion, tomographic SPECT imaging (78452) 
provided August 13, 2020. 
 
You asked the Plan to pay for myocardial perfusion, tomographic SPECT imaging. You say that the records 
attached supporting that this procedure was performed by your provided. Claim denied as duplicate in error. 
Please review and reprocess claim for reimbursement. The Plan denied your request. The Plan says this claim is 
a duplicate of previous considered charge. 
 
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 78452 is Myocardial perfusion imaging, tomographic 
(SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first 
pass or gated technique, additional quantification, when performed). 
 
We find that CPT code 78452 is not supported in the medical record. Specifically, this claim was processed on 
check dated 09/03/2020. The records do not support the service being performed by the rendering provider 
more than once for this date of service. Based on this information, we decided that Medicare rules for coverage 
of myocardial perfusion, tomographic SPECT imaging have not been met. Therefore, we decided that the Plan 
does not have to pay for myocardial perfusion, tomographic SPECT imaging (78452) provided August 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2311, E2313), color 
kit (K0108), standing system (E2301) and powered seat elevator (E2300) for a powered mobility device. 
 
You asked the Plan to pre-approve the power wheelchair accessories. You say that these accessories are 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically 
necessary. Power seat elevators, standing frames, and color kits are not a covered item. 
 
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 power wheelchair accessories. Our 
reviewer says that the expandable controller is not medically necessary. Our physician reviewer found the 
enrollee has sufficient upper extremity strength and functional ability to operate any power options through 
their own individual switches. Additionally, the power seat elevator, standing system, and color kit are not 
covered benefits. 
 
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 power wheelchair accessories have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an expandable controller (E2377, E2311, E2313), color kit (K0108), 
standing system (E2301) and powered seat elevator (E2300) for a powered mobility device.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the crown (D2750) for tooth # 18 provided on May 6, 2020. 
 
You asked the Plan to pay for the dental service. You say that the area of decay that is noted under tooth # 18 
has been present for decades. You also say that it will not impact the life span of the crown. The Plan denied 
your request. The Plan says that there is a cavity below the bone of your tooth. The Plan says that the tooth will 
not last long because the cavity is below the bone. 
 
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. The Plan covers the dental 
service when the services are medically necessary and reasonable. 
 
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 dental service. Our reviewer says that the 
crown is medically necessary. Our physician reviewer found the defect on tooth # 18 has been present for 
several decades and has not progressed. The reviewer found that this would not be a carious lesion and has 
been stable for decades, it should not be a factor in determining necessity for a crown. The reviewer found that 
the tooth otherwise has a large existing three surface amalgam restoration that appears to involve the cusps. 
Given the large existing restoration, likely failing at this point, the reviewer found that it would be reasonable 
to place a crown on this tooth. Therefore, the reviewer found that the crown on tooth #18 would be considered 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have been met. Therefore, we decided that the Plan has to pay 
for the crown (D2750) for tooth # 18 provided on May 6, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-rays you received on October 22, 2019. 
 
You asked the Plan to pay for the x-rays. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
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 services are not among 
those covered under this benefit. The Plan covers only those dental services listed in the Evidence of Coverage. 
Panoramic x-rays are not covered. Therefore, we decided that the Plan does not have to pay for the panoramic 
x-rays you received on October 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery (64635) provided. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you should not be charged an 
outpatient copayment. The Plan denied your request. The Plan says the copayment was applied 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 $250 
copayment for each Medicare covered ambulatory surgical center visit.  
 
You have been asked to pay a $250 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery (64635) 
provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the clinical records provided support the 
need for care in an LTACH. The Plan denied your request. The Plan says the guidelines for coverage of 
LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH), 
having initially been admitted with a DVT.  The enrollee was subsequently intubated/ventilated and eventually 
received a tracheotomy.  The enrollee is noted to have a poor prognosis.  There is no evidence that the enrollee 
requires services that are not currently available. There is no advantage in transferring the enrollee to the 
LTACH.  The enrollee can remain at the current ACH until such a time that no acute services are required.  The 
enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the heel stabilizers, knee braces, knee sleeves and ankle 
braces provided to the enrollee on August 26, 2020. 
 
You asked the Plan to pay for these items. You say that these items were medically necessary. The Plan denied 
your request. The Plan says that 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 the heel stabilizers, knee 
braces, knee sleeves and ankle braces provided to the enrollee on August 26, 2020.