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

We decided that the Plan does not have to pay for the laboratory services provided on May 20, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for the laboratory services. You say that the Plan should pay this claim. 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 has network providers 
available who can provide 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 laboratory services provided on May 20, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit with punch biopsy (99203, 11104, 11105) 
provided on July 23, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit with punch biopsy. You say that there are no dermatologists near 
you in-network. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. In addition, there are multiple in-network 
providers able to meet your medical needs. 
 
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 with punch biopsy (99203, 11104, 
11105) provided on July 23, 2020, by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from February 5, 2020, 
to February 6, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that some, if not all, of these drugs were 
replacement drugs for existing prescriptions which you take at home. You also say that you were not allowed to 
bring your prescriptions to the hospital with you. The Plan denied your request. The Plan says these drugs are 
not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from February 5, 2020, to February 6, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care service provided. 
 
You asked the Plan to pay for critical care service. You say that the Plan should pay the outstanding balance of 
this claim. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the documentation submitted does not support the code billed on this 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30 to 74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted 
does not show that this critical care service lasted 30 to 74 minutes in duration. Based on this information, we 
decided that Medicare rules for coverage of critical care service have not been met. Therefore, we decided that 
the Plan does not have to pay for critical care service provided.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided from May 20, 2020, 
to June 18, 2020 to the enrollee. 
 
You asked the Plan to pay for SNF services. You say that SNF services were medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria were not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF services. Our reviewer says that daily 
skilled services are not necessary.  
 
 
Our physician reviewer found the enrollee did not require skilled nursing services with the specialized skill, 
knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically 
necessary and reasonable treatment in a SNF during the dates in question. The enrollee did not have complex 
wound care or other ongoing SNF level needs. The enrollee's functional level did not require skilled therapy 
services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively 
provide medically necessary and reasonable treatment in a SNF. The enrollee did not require care on a daily 
basis. Medicare coverage criteria were not met. We looked at this physician's review, the file, and Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been 
met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility services provided 
from May 20, 2020, to June 18, 2020 to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction you had. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided during a routine exam. 
 
We looked at the file and the Plan's rules. The requested eye refraction was not provided during a routine eye 
exam. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the eye refraction you had.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014) and diagnostic imaging of retina 
(92134) provided on July 13, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for eye exam and diagnostic imaging of retina. You say that you were unaware you 
needed prior authorization. The Plan denied your request. The Plan says prior authorization must be obtained 
for non-emergent services rendered by an out-of-network provider. 
 
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 eye exam (92014) and diagnostic imaging of 
retina (92134) provided on July 13, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion supplies (A4221, A4222) provided from June 9, 
2020 to June 15, 2020. 
 
You asked the Plan to pay for infusion supplies. You say that these items were medically necessary. The Plan 
denied your request. The Plan says there is not a valid order or proof of delivery for these items. 
 
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 physician order or proof of delivery for the supplies provided in this case. 
This documentation was not included in the submitted records. 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 infusion supplies (A4221, A4222) provided from June 9, 2020 to June 15, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility visit (99308) provided on 
May 12, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility visit. You say that you would like this claim 
reprocessed and approved for payment. 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. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility visit (99308) provided on May 
12, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home sleep test (G0399) provided on December 18, 2019 
by an out of network (OON) provider. 
 
You asked the Plan to pay for home sleep test. You say that the services rendered were medically necessary. 
The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
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 home sleep test (G0399) provided on 
December 18, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard (D9944) provided. 
 
You asked the Plan to pay for the occlusal guard. You say that you contacted the Plan prior to receiving the 
service, and were told the mouth guard would be covered. The Plan denied your request. The Plan says the 
service received is not covered by Medicare. The Plan also says that you contacted the Plan, after you had 
already received the occlusal guard. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the occlusal guard (D9944) 
provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on April 7, 2020. 
 
You asked the Plan to pay for lab tests. You say that these tests are covered by Medicare. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not show that these tests were necessary for the enrollee's unique clinical scenario. 
 
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 documentation submitted does not show the specific purpose for which this testing was ordered, or that the 
results were requested in order to guide therapeutic decision-making. Medicare does not cover these tests for 
screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on 
April 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
and humidifier. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a CPAP device is covered when specific criteria 
are met. 
 
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 these services. Our reviewer says that 
you do not meet the criteria for coverage. Our physician reviewer found although the enrollee has symptoms 
consistent with obstructive sleep apnea, there is no confirmed diagnosis. Two studies have shown that the 
respiratory disturbance index (RDI) is within the normal range. The clinical notes list a diagnosis of obesity-
hypoventilation syndrome, and CPAP can be indicated in the treatment of that condition, but there is no 
documentation to support that diagnosis. There are no pulmonary function studies. The records do not support 
that the CPAP is reasonable or 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 pre-approve a continuous positive airway pressure (CPAP) device and humidifier.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient therapy provided by an out-of-network provider 
on April 7, 2020. 
 
You asked the Plan to pay for outpatient therapy. You say that the claim should be accepted and reprocessed 
for payment. The Plan denied your request. The Plan says the out-of-network 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 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 therapy provided by an out-of-network 
provider on April 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Vestibuloplasty (40840) provided October 8, 2019.You asked the Plan to pay forthe Vestibuloplasty. You say that you had to take out a loan to pay for these expenses which exceeded $8,000. You had no control nor did you know that the surgeon called in did not accept your insurance.The Plan denied your request. The Plan says this post-operative visit is not allowed because it was included in the payment for the surgical procedure.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 40840-47 is Vestibuloplasty, under repair procedures on the vestibule of mouth.We find that CPT code 40840-47 is not supported in the medical record. Specifically, 40840 was billed twice. 40840-47 also denied due to being billed within the global period of CPT code 21445 billed by the same provider on 8/10/2019. Per Medicare Claims Processing Manual Chapter 12, section 40all additional medical or surgical services required of the surgeon during the postoperative period of the global surgery because of complications which do not require additional trips to the operating room are not separately reimbursed. Based on this information, we decided that Medicare rules for coverage of the Vestibuloplasty have not been met.Therefore, we decided that the Plan does not have to pay forthe Vestibuloplasty (40840) provided October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the dermatology visit you had on August 
17, 2020. 
 
You asked the Plan to waive the copayment for the dermatology visit. You say that a resident performed your 
exam and the doctor didn't look you over. The Plan denied your request. The Plan says you were charged this 
amount 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 $45 
copayment for visits with a specialist.  
 
You have been asked to pay a $45 copayment for the dermatology visit. The dermatology visit falls within the 
visits with a 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 the 
dermatology visit you had on August 17, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for ultrasound exam. You say that authorization is not required for this service. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider 
is out-of-network with the Plan and 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 the medical services provided 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 removal of tissue from wounds (97597) provided on July 
9, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for removal of tissue from wounds. You say that the services were medically 
necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
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 removal of tissue from wounds (97597) 
provided on July 9, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the podiatry visit you had. 
 
You asked the Plan to waive the copayment for the podiatry visit. You say that you have not had to pay a 
copayment for podiatry services in the past. The Plan denied your request. The Plan says you were charged this 
copayment 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 $35 
copayment for podiatry services.  
 
You have been asked to pay a $35 copayment for the podiatry visit. This copayment applies regardless of 
whether you have been charged in the past. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the podiatry 
visit you had.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 8, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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, the laboratory services, 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 the laboratory services provided on June 8, 2020.