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

 
We decided that the Plan does not have to pay for the radiation physics consult provided on April 3, 2020 by an 
out of network provider. 
 
You asked the Plan to pay for the radiation physics consult (77336). 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 service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the radiation physics consult provided on April 3, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visit, durable medical 
equipment, and physical therapy (PT) rendered from May 20, 2020 to June 2, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that you should not be responsible for 
the copayments because your injury is the hospital's fault. The Plan denied your request. The Plan says the 
copayments were 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 $25 
copayment for per specialist office visit, a 20% coinsurance for durable medical equipment and related 
supplies, and a $25 copayment per therapy type, per provider, per day for physical and speech therapy. 
 
Review of the file shows that you received specialist services on May 20, 2020. You have been asked to pay a 
$25 copayment for these services. These services fall within the specialist office visit benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan.  
 
The file shows that you received a walking boot on May 20, 2020. You have been asked to pay a 20% 
coinsurance for these services. These services fall within the durable medical equipment and related supplies 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. 
 
The file shows that you received PT services on May 26, 2020; May 28, 2020; and June 2, 2020. You have 
been asked to pay a $25 copayment per date of service for these services, for a total of $75. These services fall 
within the physical and speech therapy 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 copayments for the office visit, durable medical equipment, 
and physical therapy (PT) rendered from May 20, 2020 to June 2, 2020.  
 
Your complaint about hospital is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient level of care provided on January 30, 2020. 
 
You asked the Plan to pay for the inpatient level of care. You say that the inpatient level of care was medically 
necessary as the enrollee was under anesthesia and while under anesthesia he developed bradycardia and 
hypotension. The Plan denied your request. The Plan says the inpatient level of care was not medically 
necessary as the inpatient only procedure was cancelled due to the enrollee needing a cardiac evaluation. 
 
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 the inpatient level of care. Our reviewer says 
that the inpatient level of care was not medically necessary. Our physician reviewer found the review indicates 
that on 1/30/20 the enrollee was prepared for revision reverse total right shoulder and had been sedated and 
intubated and was being positioned for surgery when it was identified that his heart rate (HR) had slowed to the 
20-30s with significant ST depression and he had no measurable BP. He was given Glycopyrrolate and 
Neosynephrine after which his HR came back up in the 50s/60s and he had a BP. At that point the surgery was 
canceled, and cardiology was consulted. He reportedly felt well with no chest pain, shortness of breath, 
dizziness or palpitations. 
The review has determined that the inpatient level of care 1/30/20 was not medically reasonable or necessary 
for the enrollee in this case based on the documentation provided. The enrollee could have been monitored 
under observation status. 
 
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 inpatient level of care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient level of care provided on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on April 24, 
2020. 
 
You asked the Plan to pay for these services. You say that you should get an exception to the contract rule due 
to Covid 19. 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 April 24, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an abdominal ultrasound (76700), an 
ultrasound behind the abdominal cavity (76770), a pelvic ultrasound (76856), and a liver elastography (91200) 
performed on February 29, 2020. 
 
You asked the Plan to waive the copayments for 3 ultrasounds and a liver elastography. You say that you want 
to make certain that you are being billed accurately. The Plan denied your request. The Plan says the correct 
copayments were 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 $155 
copayment for each Medicare-covered radiological diagnostic service, not including X-rays.  
 
You have been asked to pay $620, or a $155 copayment per procedure, for 3 ultrasounds and a liver 
elastography. These procedures fall 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 copayments for an abdominal ultrasound 
(76700), an ultrasound behind the abdominal cavity (76770), a pelvic ultrasound (76856), and a liver 
elastography (91200) performed on February 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960), a wrist-hand orthosis 
(L3916), a knee orthosis with suspension sleeve and knee accessories (L1851, L2397, L2385, L2820, L2830), 
and an ankle-foot orthosis with stabilizer (L1971, L3170) provided to the enrollee on April 29, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist 
orthosis (L3960), a wrist-hand orthosis (L3916), a knee orthosis with suspension sleeve and knee accessories 
(L1851, L2397, L2385, L2820, L2830), and an ankle-foot orthosis with stabilizer (L1971, L3170) provided to 
the enrollee on April 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on March 18, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 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 a domiciliary, rest home visit provided on March 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wheelchair purchased on November 28, 2019. 
 
You asked the Plan to pay for this wheelchair. You say that this wheelchair should be covered by the Plan. The 
Plan denied your request. The Plan says you did not have prior authorization for a wheelchair and there are no 
medical records submitted to show you met the required coverage criteria for a wheelchair at the time of 
purchase. 
 
Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says 
that durable medical equipment may require prior authorization. You did not have prior authorization to 
purchase or rent a wheelchair. The appropriate medical records to show a manual wheelchair was necessary in 
the home were not submitted prior to purchase. 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 a wheelchair purchased on 
November 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoride varnish application (D1206) and unspecified 
periodontal procedure (D4999) provided on November 5, 2019 and November 6, 2019. 
 
You asked the Plan to pay for the fluoride varnish application (D1206) and unspecified periodontal procedure 
(D4999). You say that this is a necessary treatment for gum disease. You say that the services were necessary 
to maintain and healthy body. The Plan denied your request. The Plan says the services are not covered 
benefits. 
 
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 
fluoride varnish application (D1206) and unspecified periodontal procedure (D4999) provided on November 5, 
2019 and November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a single, upright, prefabricated, off-the-shelf knee orthosis 
(HCPCS L1851) and an suspension sleeve addition to a lower extremity orthosis (HCPCS L2397) provided on 
March 19, 2020. 
 
You asked the Plan to pay for HCPCS codes L1851 and L2397. You say that the medical records provided 
support the need for the requested HCPCS codes. The Plan denied your request. The Plan says the Medicare 
rules for payment of the items which remain in dispute have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of the knee 
orthosis represented by CPT code L1851 is 3 years. Medicare rules also say that L-coded additions to knee 
orthoses will be denied as noncovered when the base orthosis is noncovered. 
 
We looked at the file and Medicare rules. The records show that payment was made to a different provider on 
HCPCS codes L1851 and L2397 for date of service February 18, 2020. The records did not show 
documentation demonstrating that these items were irreparably damaged or that replacement was necessary due 
to loss. The reasonable and useful lifetime of HCPCS code L1851 is 3 years, which has not passed. HCPCS 
code L2397 is noncovered since the base code is being denied as noncovered. Based on this information, we 
decided that Medicare rules for coverage of HCPCS codes L1851 and L2397 have not been met. Therefore, we 
decided that the Plan does not have to pay for a single, upright, prefabricated, off-the-shelf knee orthosis 
(HCPCS L1851) and an suspension sleeve addition to a lower extremity orthosis (HCPCS L2397) provided on 
March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on May 23, 2018. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim was not filed timely per Medicare 
criteria. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physician services was not filed until October 19, 2019. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the physician services provided on May 23, 2018.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the outpatient surgical services rendered 
on January 21, 2020. 
 
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the cost sharing was 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 there is $500 yearly deductible for your covered medical services and a $325 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges. 
 
Review of the file shows that you received outpatient surgical services on January 21, 2020. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is $500 yearly deductible for your 
covered medical services. This cost sharing is a contractual obligation that had not been met at the time these 
services were received on January 21, 2020. The Plan applied $420.29 to the deductible for these services. 
Given that the deductible did not cover the entire cost of the services, you have also been asked to pay a $350 
copayment for these services. 
 
The total amount you have been asked to pay for these services is $745.29 for these services. This cost sharing 
is a contractual obligation that you agreed to pay when you enrolled in the Plan. Therefore, we decided that the 
Plan does not have to waive the cost sharing for the outpatient surgical services rendered on January 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance procedure (D4910) provided on 
February 19, 2020. 
 
You asked the Plan to pay for the periodontal maintenance procedure (D4910). You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the dental services you 
received are not covered by Medicare or the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the periodontal services you received 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the periodontal maintenance procedure (D4910) provided on February 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950) for tooth #'s 24 and 25. 
 
You asked the Plan to pre-approve core buildup (D2950) for tooth #'s 24 and 25. You say that a crown must be 
placed to build back tooth structure for overall dental health. The Plan denied your request. The Plan says the 
service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup (D2950) for tooth #'s 24 and 25.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0433) provided 
on March 6, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this payment should be 
reconsidered. The Plan denied your request. The Plan says the enrollee was charged this cost sharing 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). The enrollee's contract with the Plan clearly says that the enrollee 
must pay a $275 copayment for each ambulance trip. The enrollee had 1 ambulance trip(s). The Plan charged 
the enrollee $275 for these services. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
when the enrollee enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the ambulance services (A0433) provided on March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that 
the member must receive care from a network provider and in most cases, care received from an out-of-
network provider will not be covered, except for emergency care or urgently needed services and needed 
medical care that Medicare requires our plan to cover and the providers in our network cannot provide this 
care, which requires 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's optometry services provided on June 1, 2020. 
 
You asked the Plan to pay for the physician's optometry services. The Plan denied your request. The Plan says 
you must receive care from in-network providers with the exception of emergency or urgent care, dialysis 
while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, 
which requires prior authorization from the plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 physician's optometry services provided on June 1, 2020.