Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive, new patient ophthalmological medical 
examination and evaluation with initiation of a diagnostic and treatment program (92004) and the 
determination of a refractive state (92015) rendered by the out of network (OON) provider on September 2, 
2020. 
 
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 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 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 comprehensive, new patient ophthalmological medical examination and evaluation 
with initiation of a diagnostic and treatment program (92004) and the determination of a refractive state 
(92015) rendered by the out of network (OON) provider on September 2, 2020.
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 enrollee is currently unable to sit. 
The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute 
setting. 
 
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 physician 
reviewer found that the enrollee was admitted to the current acute care hospital with sepsis, bacteremia from 
likely UTI, septic arthritis, rhabdomyolysis, and acute on chronic kidney injury. He was treated with 
antibiotics, hemodialysis, epoetin, wound care, knee washout, and synovectomy. Recent notes state that the 
right knee wound at the site of the arthrotomy is healing poorly, but other wounds are healing. He is being 
treated with dressing changes only at this time. The enrollee appears to be improving gradually. Although he 
requires additional acute care hospital services, the enrollee does not require any services at the LTACH that 
are not already available at the current hospital. The enrollee does not have complex wound care needs at this 
time. Therefore, this request for LTACH services will be considered not 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on June 2, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the member's primary care physician did not refer these services. 
 
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 lab work provided on June 2, 2020 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 complete maxillary overdenture (D5863) provided on 
June 5, 2020. 
 
You asked the Plan to pay for the complete maxillary overdenture. The Plan denied your request. The Plan says 
this service is not a covered benefit under your dental plan. 
 
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 pay for the 
complete maxillary overdenture (D5863) provided on June 5, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the chest (71550). 
 
You asked the Plan to pre-approve a MRI of the chest. You say that this is necessary rule out any structural 
abnormalities. The Plan denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MRI of the chest. Our reviewer says 
that the requested MRI is medically necessary. Our physician reviewer found studies have  found that the 
prevalence was relatively even across age groups and that hypertrophy of the ligamentum flavum increased 
with age and was higher in female patients.  The requested procedure is medically reasonable and 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 a MRI of the chest have been met. Therefore, we decided that the Plan has to 
pre-approve a magnetic resonance imaging (MRI) of the chest (71550).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the MRI scan coded 72141 provided on June 24, 2020. 
 
You asked the Plan to pay for the MRI scan. 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 72141 is magnetic resonance (eg, proton) imaging, spinal 
canal and contents, cervical; without contrast material. 
 
We find that CPT code 72141 is not supported in the medical record. Specifically, the submitted documentation 
supports one unit of this code, which was previously approved and processed by the plan. There is no 
additional documentation supporting an additional study. Based on this information, we decided that Medicare 
rules for coverage of the MRI scan have not been met. Therefore, we decided that the Plan does not have to pay 
for the MRI scan coded 72141 provided on June 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that all physicians involved with the 
enrollee's care concur that LTACH is the appropriate level of care. The Plan denied your request. The Plan says 
rules for 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 that the enrollee appears to be stabilizing and improving with treatment, but requires 
additional short term acute care services to help further wean from high flow oxygen, which can safely be 
completed in the current facility and is likely to not exceed an additional 24 days. The enrollee does not require 
services in the LTACH that are not already available at the current facility. There are no services at the 
LTACH that are not already available and covered at the current facility. 
 
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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for prostatic arterial embolization (PAE) procedure provided on 
May 18, 2020. 
 
You asked the Plan to pay for PAE procedure. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of payment for this service is correct, because this procedure is 
experimental and was not furnished within the accepted standards of current medical practice. 
 
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 pay for PAE procedure. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found prostatic arterial embolization (PAE) is an experimental technique to treat symptomatic benign 
prostatic hyperplasia (BPH). Very limited international studies have demonstrated possible short-term safety 
and efficacy. Comparative studies to other methods are currently enrolling patients. The most recent guidelines 
do not recommend this procedure outside of a clinical trial setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PAE procedure have not been met. Therefore, we decided that the Plan does not 
have to pay for prostatic arterial embolization (PAE) procedure provided on May 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80048, 84436, 84443, 84479, 85025, 
P9604) provided on November 21, 2019. 
  
You asked the Plan to pay for laboratory services. You say that these tests are supported by the records. The 
Plan denied your request. The Plan says there is not a physician order for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. The rules also say that while a physician order is not required to be signed, the 
physician must clearly document, in the medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. The submitted documentation does not include a physician order or 
clear documentation indicating intent for these tests to be performed. There are no submitted medical records 
indicating that these services were medically necessary. Based on this information, we decided that Medicare 
rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory services (80048, 84436, 84443, 84479, 85025, P9604) provided on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy services provided from December 11, 
2019, to December 17, 2019. 
 
You asked the Plan to pay for home infusion therapy services. You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says this procedure code is not valid for Medicare purposes. 
 
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 S9502 is Home infusion therapy, antibiotic, antiviral, or 
antifungal therapy; once every 8 hours, administrative services, professional pharmacy services, care 
coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. 
 
We find that CPT code S9502 is not a valid code for Medicare purposes. S codes are unique temporary codes 
established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare 
uses another code for reporting of, and payment for, these services. Based on this information, we decided that 
Medicare rules for coverage of home infusion therapy management have not been met. Therefore, we decided 
that the Plan does not have to pay for home infusion therapy services provided from December 11, 2019, to 
December 17, 2019.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for out of network physician services provided on September 10, 2019 at 
the in-network rate. 
 
You asked the Plan to pay for these services at the in-network rate. You say that you were referred by your 
Plan physician and were not aware this provider was out of network. The Plan denied your request. The Plan 
says that this cost share was applied due to the claim submitted by the provider. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. The Plan acknowledges that you were referred by a Plan provider. Any issues 
with the claim regarding the out of network deductible or billing errors are not under your control. You were 
referred for these services by a contract provider. Under Medicare rules, this means these services are 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for out of network physician 
services provided on September 10, 2019 at the in-network rate.  
 
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 frenulectomy (D7960) and the free soft tissue graft 
procedure (D4277) provided on July 1, 2020. 
 
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 the dental services provided are not a covered 
benefit under your contractual policy. 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the frenulectomy 
(D7960) and the free soft tissue graft procedure (D4277) provided on July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sedation services (99152) provided on May 12, 2020. 
 
You asked the Plan to pay for sedation services. You say that this is documented in the records. The Plan 
denied your request. The Plan says this is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the submitted records do not 
contain documentation of the presence of an independent trained observer. Based on this information, we 
decided that Medicare rules for coverage of sedation services have not been met. Therefore, we decided that the 
Plan does not have to pay for sedation services (99152) provided on May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for laboratory services and annual wellness visit 
provided on June 15, 2020, and June 22, 2020. 
 
You asked the Plan to waive the cost for the laboratory services and annual wellness visit. You say that you 
have been going to this provider for years and were never charged. You say that you were never informed the 
provider is out-of-network. The Plan denied your request. The Plan says the cost share applied correctly. 
 
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 your yearly out-of-network deductible is $250. This is the amount you have to 
pay out-of-pocket before we will pay our share for your covered out-of-network medical services. Until you 
have paid the deductible amount, you must pay the full cost for most of your out-of-network covered services. 
Your contract with the Plan says that you must pay a $25 copayment for an out-of-network annual wellness 
visit. 
 
The item or service you asked the Plan to waive the cost for falls within the "Outpatient diagnostic tests and 
therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing 
in the contract that your yearly out-of-network deductible is $250. This cost sharing is a contractual obligation 
that had not been met at the time the laboratory services were received on June 15, 2020. Therefore, $13.94 has 
been applied to your deductible. 
  
 
 
You have also been asked to pay a $25 copayment for your annual wellness visit. The annual wellness visit 
falls within the 'Annual wellness visit' 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 cost for 
laboratory services and annual wellness visit provided on June 15, 2020, and June 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy provided on July 15, 2020 by an 
OON provider. 
 
You asked the Plan to pay for the endodontic therapy. You say that your dentist scheduled this appointment 
because they felt it was necessary. You also say that this provider is the only local dentist who does root canals. 
The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The 
Plan also says that services performed by non-participating providers are not covered. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
endodontic therapy provided on July 15, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the chemodenervation and botox injections 
provided on April 30, 2020. 
 
You asked the Plan to waive the cost for the chemodenervation and botox injections. You say that you were 
informed you could use the savings program to pay for the injections, but you weren't eligible. You say that 
you wouldn't have gotten the injections if you knew you would have to pay. The Plan denied your request. The 
Plan says the cost share 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 $35 
copayment for each Medicare-covered specialist visit and 20% coinsurance for Medicare-covered Part B 
chemotherapy drugs and other Part B drugs.  
 
You have been asked to pay a total of $279.40 for the chemodenervation and botox injections.  
 
Service Allowed Amount Standard Cost Member Liability 
Chemodenervation $165.85 $35 $35 
Botox Injections $1,222 20% $244.40 
TOTAL:   $279.40 
 
The chemodenervation falls within the "Physician/Practitioner services, including doctor's office visits benefit 
category. The botox injections fall within the Medicare Part B prescription drugs" 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 cost for the chemodenervation and botox injections provided on April 30, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210) provided on June 16, 2020. 
 
You asked the Plan to pay for the dental service. You say that your tooth was broken off and causing you pain. 
You also say that this should be covered. The Plan denied your request. The Plan says the extraction is not 
listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the extraction is not among those 
covered under this benefit. The record shows that you were not enrolled in the Dental Platinum Rider in June 
2020. Additionally, the Evidence of Coverage clearly states that any services not listed are not covered.  
Therefore, we decided that the Plan does not have to pay for the extraction (D7210) provided on June 16, 2020.