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

 
We decided that the Plan does not have to pre-approve the Oxycontin 20mg ER tablet medication. 
 
You asked the Plan to pre-approve this medication. You say that the patient has been on this medication since 
2007 for lumbar radiculopathy. The Plan denied your request. The Plan says this medication is not a covered 
benefit under the enrollee's contractual policy. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Oxycontin 20mg ER 
tablet medication.  
 
Benefits for this medication 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the electrocardiogram (93010) provided on June 1, 2020. 
 
You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that MS does not separately pay any provider 
or supplier other than the facility for services furnished to the beneficiary for surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that A/B MACs (B) must pay for the PC of radiology services furnished by a physician to an 
individual patient in all settings under the fee schedule for physician services regardless of the specialty of the 
physician who performs the service. 
 
We find that CPT code 93010 is supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 93010 has a Pro/Tech Flag of 2. This indicator identifies stand-alone codes that describe the physician 
work portion of selected diagnostic tests for which there is an associated code that describes the technical 
component of the diagnostic test only and another associated code that describes the global test. Based on this 
information, we decided that Medicare rules for coverage of the electrocardiogram have been met. Therefore, 
we decided that the Plan has to pay for the electrocardiogram (93010) provided on June 1, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee on September 
22, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim cannot be paid due to the status code indicator of "I" for the codes submitted. 
 
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 status code on the services 
submitted prevents payment on Medicare claims. Medicare rules for coverage of this service have not been 
met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee 
on September 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of x-rays (D0210) provided on 
September 28, 2020. 
 
You asked the Plan to pay for the dental service. You say that routine dental services are covered by your 
insurance. The Plan denied your request. The Plan says complete series of x-rays are covered once every 5 
years. The Plan says that the frequency limit has been reached. 
 
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 frequency limit of 1 complete 
series x-ray every 5 years has been exceeded. The record shows that the Plan paid for this x-ray that you 
received on May 9, 2018, less than 5 years ago. Therefore, we decided that the Plan does not have to pay for 
the complete series of x-rays (D0210) provided on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure, problem focused limited oral 
evaluation, and first intraoral periapical x-ray provided on August 26, 2020. 
 
You asked the Plan to pay for the preventive procedure, problem focused limited oral evaluation, and first 
intraoral periapical x-ray. You say that you believe these services should be covered. The Plan denied your 
request. The Plan says the preventive procedure is not a covered benefit. The Plan also says that your benefits 
for the problem focused limited oral evaluation and first intraoral periapical x-ray have been satisfied and the 
frequency limitations have 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, the unspecified preventive procedure is 
not among those covered under this benefit. The contract says that exams (including periodic oral exams and 
emergency diagnostic exams) are limited to two procedures per calendar year. The record shows that you 
received periodic oral exams on February 17, 2020, and August 19, 2020, and your exams benefit had been 
exhausted. The Plan also says that intraoral x-rays are limited to one procedure per calendar year. The record 
shows that you received a first intraoral periapical x-ray on February 17, 2020, and your intraoral x-rays benefit 
had been exhausted. Therefore, we decided that the Plan does not have to pay for the preventive procedure, 
problem focused limited oral evaluation, and first intraoral periapical x-ray provided on August 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on May 24, 2020 and 
billed under codes 81401, 81403, 81405, 81406, 81407 and 81408. 
 
You asked the Plan to pay this claim. You stated these services should be covered by the Plan. The Plan denied 
your request. The Plan states that the services provided on May 24, 2020 could not be paid due to the 
submission of an incorrect Place of Service (POS) code. The submitted claim form indicates the laboratory 
specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim 
history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results 
submitted indicate the specimen was collected on May 4, 2020 and received by the lab on June 2, 2020; 
therefore, the billed codes 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 CPT code. In this case, the claim cannot be paid as billed 
due to an issue with the POS code. Medicare billing criteria are not met. Therefore, we decided that the Plan 
does not have to pay for lab services provided to the enrollee on May 24, 2020 and billed under codes 81401, 
81403, 81405, 81406, 81407 and 81408.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010). 
 
You asked the Plan to pre-approve the endosteal implant. You say that you would like a one-time exception 
made for the endosteal implant. The Plan denied your request. The Plan says this service is not covered under 
your 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 
surgical placement of implant body: endosteal implant (D6010).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on August 14, 2020. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan because you 
were referred by your physician. The Plan denied your request. The Plan says you did not have prior 
authorization for out of network care and the referring physician was also out of 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 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 physician services provided 
on August 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for intermediate proton beam therapy delivery 
(77523) on page July 30, 2020. 
 
You asked the Plan to waive the copayment for intermediate proton beam therapy delivery. You say that the 
enrollee is in a Medicare approved clinical trial and the plan must process the clinical trial claims as in-
network, therefore the in-network copay should be applied. The Plan denied your request. The Plan says the 
claim was processed and the proper 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 $50 
copayment for Medicare covered radiation therapy services.  
 
You have been asked to pay $50 copayment for intermediate proton beam therapy delivery. Intermediate 
proton beam therapy delivery 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 intermediate proton beam 
therapy delivery (77523) on page July 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite one surface anterior (D2330) provided 
on September 1, 2020. 
 
You asked the Plan to pay for resin-based composite one surface anterior. You say that the service should be 
covered. The Plan denied your request. The Plan says the maximum benefit frequency for this service has been 
exhausted. 
 
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. Specifically, records indicated you have already received this service 
twice in the 2020 calendar year. This means you have exceeded the maximum benefit frequency, and therefore, 
this service is not a covered benefit. Therefore, we decided that the Plan does not have to pay for resin-based 
composite one surface anterior (D2330) provided on September 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need the rides to go 
to your doctor's appointment and cannot be sitting for too long since your legs are really bad. The Plan denied 
your request. The Plan says you exhausted your benefit. Medicare does not cover transport in a vehicle that is 
not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that 
reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 one-way trips per year. 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. The 49th trip and 
beyond is not a covered benefit. Your EOC states routine transportation for up to forty-eight (48) one-way 
transportation trips per calendar year. As the year has changed since the appeal began, please check your 2021 
EOC for coverage rules regarding routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry services provided on July 21, 2020. 
You asked the Plan to waive the copayment for the podiatry services. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received podiatry services on the date of service at issue in this appeal. The 
Plan says that the correct copayment has applied per your contract with the Plan. 
 
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.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received podiatry services 
on July 21, 2020. You have been asked to pay a $35 copayment for the podiatry services. The podiatry services 
fall within the Podiatry 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 
the podiatry services provided on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pre-operative tests for cataract surgery. 
 
You asked the Plan to pre-approve the tests. You say that this is medically necessary. The Plan denied your 
request. The Plan says additional tests are not reasonable and necessary unless there is an additional diagnosis 
and the medical need for the additional test is fully documented. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the tests. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the information in the case file does not specify what pre-operative testing has been requested. The 
medical records provided are not related to cataract surgery, and do not support the need for pre-operative 
evaluation testing prior to cataract surgery. 
 
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 tests have not been met. Therefore, we decided that the Plan does not have 
to pre-approve pre-operative tests for cataract surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on June 4, 2020. 
 
You asked the Plan to pay for this service. You say that you needed to go out of network because a previous 
appointment was cancelled. The Plan denied your request. The Plan says you did not have prior authorization 
for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. 
The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan 
did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for 
these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician 
services provided on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a grab bar. 
 
You asked the Plan to pre-approve a grab bar. You say that you would like reconsideration because you require 
this item for your bathroom and without it your ability to get around is affected. The Plan denied your request. 
The Plan says a grab bar is a non-medical item used for convenience. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on June 16, 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 that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan is denying payment for the laboratory services because the 
claim was billed with place of service 22 (outpatient) and the claim history shows the enrollee was inpatient 
during the date of service at issue in this appeal. However, the Plan has not provided the claim history for 
review or any other records to show the enrollee was inpatient on June 16, 2020. We find that the Plan has 
provided insufficient information to support their reasoning for denial of payment based on Medicare criteria.  
Therefore, we decided that the Plan has to pay for the laboratory services provided on June 16, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for trigger 
finger surgery for the enrollee. 
 
You asked the Plan to pre-approve the referral. You say that the enrollee cannot schedule the procedure at the 
local in-network facility due to COVID-19 restrictions on elective surgery. 
 The Plan denied your request. The Plan says there are in-network providers and the procedure is neither urgent 
or emergent. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
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 referral. Our reviewer says that the 
requested referral is not medically reasonable or necessary. Our physician reviewer found the enrollee presents 
with right middle finger pain and triggering. His middle finger has been progressively worse and catches quite 
significantly. Functional limitation is reported in gripping and moving things. He has not improved with rest 
and time. He has been recommended for right middle trigger finger release. Under consideration is a request for 
referral to an out-of-network provider for trigger finger surgery. It was noted that he could not currently 
schedule the procedure at his local in-network facility due to COVID-19 restrictions on elective surgery, and 
had made arrangements to travel to another hospital as there were less COVID patients. The out-of-network 
provided indicated that the enrollee had some urgency to the procedure as he had already planned on it and 
arranged for family to help take care of him while he recovered from surgery. Medicare criteria for an urgent 
surgery had not been met in this case. The requested surgery should not be considered urgent enough that it is 
required to get it immediately at an out-of-network facility with less COVID patients. 
 
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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a referral to an out-of-network provider for trigger finger surgery for the enrollee.