Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the echocardiogram you had on May 5, 
2020. 
 
You asked the Plan to waive the copayment for the echocardiogram. You say that you should only be 
responsible for the office visit copayment since you were never told there would be additional charges. 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 $20 
copayment for non-radiological diagnostic services.  
 
You have been asked to pay a $17.98 copayment for the echocardiogram. Your copayment obligation for non-
radiological diagnostic tests is $20, but the allowed amount for this service is less than the copayment owed.  
That is why the plan is only charging you $17.98. The echocardiogram falls within the non-radiological 
diagnostic services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. In addition, please note that page 4-6 of your Evidence of Coverage also states that you may have 
more than one cost share if you get more than one service at an appointment. Therefore, we decided that the 
Plan does not have to waive the copayment for the echocardiogram you had on May 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 30, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code  is not supported in the records. Specifically, the documentation provided does not 
indicate that the specimen was obtained at an independent laboratory. Based on this information, we decided 
that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay 
for the lab services provided on April 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on December 12, 2018 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that please reconsider for payment. At the time 
of services there was another payer listed as primary, but they recouped their payment due to updated 
coordination of benefits. The Plan denied your request. The Plan says enrollee's 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 outpatient services provided on December 12, 
2018 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in incision and drainage procedure you had 
at an outpatient hospital facility on March 29, 2020. 
 
You asked the Plan to waive the copayment for the outpatient hospital facility services. You say that your 
doctor should have disclosed that you would owe an outpatient hospital copayment for this service. 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 $295 
copayment for surgery or other services provided an outpatient hospital.  
 
You have been asked to pay a $295 copayment for the outpatient hospital facility services. Records show that 
the services you had were rendered at an outpatient hospital facility. 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 in incision and drainage procedure you had at an outpatient hospital facility on March 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for DME and related supplies provided on May 
18, 2020. 
 
You asked the Plan to waive the deductible for DME and related supplies. You say that you disagree with the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible for DME and related supplies.  
 
You received DME and related supplies on May 18, 2020. The record shows that you had only paid $25 toward 
the $500 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed 
amount of $238.24.   
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category DME and 
related supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 
deductible for DME and related supplies. This cost sharing is a contractual obligation that had not been met at 
the time DME and related supplies was received on May 18, 2020. Therefore, we decided that the Plan does 
not have to waive the deductible for DME and related supplies provided on May 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and the pneumococcal conjugate 
vaccine (90670) rendered by the out of network (OON) provider on December 12, 2019. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services were rendered by an out of 
network provider, 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 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 office visit (99213) and the pneumococcal conjugate vaccine (90670) rendered by 
the out of network (OON) provider on December 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthotics rendered on November 14, 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 there is no valid physician order or proof of delivery. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any DMEPOS item to a beneficiary. The Plan must follow Medicare rules. The 
Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of 
delivery. 
 
We looked at the file and Medicare rules. There is no valid physician order or proof of delivery for the DME. 
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 orthotics rendered on November 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal foreign body from external auditory canal 
services coded 69200 provided on February 16, 2020. 
 
You asked the Plan to pay for the removal foreign body from external auditory canal services. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 
are not supported by the documentation. 
 
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 69200 is removal foreign body from external auditory 
canal; without general anesthesia. 
 
We find that CPT code 69200 is not supported in the medical record. Specifically, the documentation shows 
that the services provided were cerumen removal from the eat. There is a more appropriate code to describe the 
services provided. Based on this information, we decided that Medicare rules for coverage of the removal 
foreign body from external auditory canal services have not been met. Therefore, we decided that the Plan does 
not have to pay for the removal foreign body from external auditory canal services coded 69200 provided on 
February 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 11, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the outpatient services (G0467 and 99213). You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says utilization of 
network providers is required when possible and available. 
 
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 on March 11, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary immediate denture (D5130) and a 
mandibular immediate denture (D5140). 
 
You asked the Plan to pre-approve the maxillary and mandibular immediate dentures. You say that your 
previous dentures do not fit. You also say that you were advised you would need new dentures instead of 
repairing your previous dentures. The Plan denied your request. The Plan says based on the documents 
submitted, you have already had your teeth extracted previously, and also had an existing denture. 
 
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, a maxillary immediate denture 
(D5130) and a mandibular immediate denture (D5140) can each be delivered at the time of extracting the 
remaining upper teeth. The x-rays provided show that you currently have any teeth to remove, requiring an 
immediate maxillary and mandibular denture. Therefore, we decided that the Plan does not have to pre-approve 
a maxillary immediate denture (D5130) and a mandibular immediate denture (D5140).
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 enrollee needs daily therapy and physician oversight. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for revision of a left knee arthroplasty. His medical problems are stable. He has no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 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 a telemedicine visit provided on April 30, 2020. 
 
You asked the Plan to pay for telemedicine visit. You say that you are appealing the Plan's denial. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because no medical records 
were supplied to substantiate that this visit was performed for covered reasons. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary must 
furnish to the Plan sufficient information to determine whether payment is due for a claim.  
 
We looked at the file and Medicare rules. No medical records for this visit were submitted to the Plan. The Plan 
requested supporting records but they were not submitted. Without this information, the need for this 
telemedicine visit has not been supported at this time. Based on this information, we decided that Medicare 
rules for coverage of telemedicine visit have not been met. Therefore, we decided that the Plan does not have to 
pay for a telemedicine visit provided on April 30, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown on tooth #18. 
 
You asked the Plan to pre-approve a crown on tooth #18. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pre-approve a crown on tooth #18. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation provided meets the criteria for coverage for a crown restoration 
for tooth #18. The bone support appears adequate and the coronal structure has significant breakdown. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a crown on tooth #18 have been met. Therefore, we decided that the Plan has to 
pre-approve a crown on tooth #18.  
 
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 rest home visit (99337) provided on February 18, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for an OON rest home visit. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was 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 the rest home visit (99337) provided on February 
18, 2020 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 medical services provided on February 13, 2020 by an 
out of network (OON) provider. 
 
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 services were rendered by an out-of-network provider 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 the medical services provided on February 13, 
2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI of the brain stem (70553) 
performed on May 10, 2020. 
 
You asked the Plan to waive the copayment for an MRI of the brain stem. You say that this service was 
medically necessary. 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 $275 
copayment for diagnostic radiology other than CT scans.  
 
You have been asked to pay a $275 copayment for an MRI of the brain stem. An MRI of the brain stem falls 
within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an MRI of the brain stem (70553) performed on May 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown. 
 
You asked the Plan to pre-approve the crown. You say that you were told that the Plan covers crowns. The Plan 
denied your request. The Plan says this service is not covered under the enrollee's benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
crown.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics rendered on January 16, 2020. 
 
You asked the Plan to pay for these services. You say that you would not have purchased the insoles if your 
doctor had not advised you to. The Plan denied your request. The Plan says the services are not covered. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for the foot orthotics rendered on January 
16, 2020.