Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom wheelchair to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a custom wheelchair to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide this item. Therefore, coverage criteria has not been met. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a custom wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan provided on July 20, 2020. 
 
You asked the Plan to pay for the CT 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 payable. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the code for the CT scan (72192) was also billed with 74177 (Computed tomography, 
abdomen and pelvis; with contrast material(s)). The documentation supports that these services were performed 
at the same enrollee encounter and therefore, not separately payable. Based on this information, we decided 
that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we 
decided that the Plan does not have to pay for the CT scan provided on July 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prolonged services (99357) provided on July 22, 2019. 
 
You asked the Plan to pay for prolonged services. You say that this code is supported. The Plan denied your 
request. The Plan says the time spent on this service is not separately billable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that prolonged service of less 
than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported 
separately. 
 
In this case, the CPT Code Manual definition of code 99357 is prolonged service in the inpatient or observation 
setting, requiring unit/floor time beyond the usual service; each additional 30 minutes (List separately in 
addition to code for prolonged service). 
 
We find that CPT code 99357 is not supported in the medical record. Specifically, the record shows that this 
was used to report prolonged services less than 15 minutes beyond the first hour. Based on this information, we 
decided that Medicare rules for coverage of prolonged services have not been met. Therefore, we decided that 
the Plan does not have to pay for prolonged services (99357) provided on July 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lead wires (A4557) provided on September 26, 2020. 
 
You asked the Plan to pay for the lead wires (A4557). You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says a TENS device was purchased in the previous 12 months therefore the lead 
wires have been denied. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The record shows a TENS device was purchased on April 26, 2020 
and records supporting the medical necessity of the additional lead wires were not submitted. Based on this 
information, we decided that Medicare rules for coverage of lead wires (A4557) have not been met.  Therefore, 
we decided that the Plan does not have to pay for lead wires (A4557) provided on September 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oncology gene expression (0005U) provided on June 25, 
2020. 
 
You asked the Plan to pay for the oncology gene expression. You say that you would like reconsideration 
because this testing is medically necessary. The Plan denied your request. The Plan says this is not a Medicare 
covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 0005U is not supported in the record. Specifically, per the Local Coverage 
Determination (LCD): Biomarkers for Oncology (L35396), CPT code 0005U is non-covered. Based on this 
information, we decided that Medicare rules for coverage of the oncology gene expression have not been met. 
Therefore, we decided that the Plan does not have to pay for an oncology gene expression (0005U) provided on 
June 25, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an ultrasound provided by a participating 
provider on September 4, 2020. 
 
You asked the Plan to waive the deductible for an ultrasound. You say that you do not agree with this charge. 
The Plan denied your request. The Plan says the correct deductible has been applied. 
 
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 $750 deductible for outpatient diagnostic tests.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible for outpatient diagnostic tests. This cost sharing is a contractual obligation that had not been met at 
the time an ultrasound was received on September 4, 2020. The total amount you are being asked to pay is 
$155.73. Therefore, we decided that the Plan does not have to waive the deductible for an ultrasound provided 
by a participating provider on September 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable x-ray services (71046, Q0092, R0070) provided 
on July 31, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON portable x-ray services. You say that these services should be treated like 
emergency services. The Plan denied your request. The Plan says these services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided 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 portable x-ray services (71046, Q0092, R0070) 
provided on July 31, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the limited oral evaluation (D0140), the periapical x-
ray (D0220), and 4 extractions (D7140) provided from August 11, 2020, to August 20, 2020. 
 
You asked the Plan to pay more for the dental services. You say that the services need to be paid. The Plan 
denied your request. The Plan says the provider in this case is out of network. The Plan also says that out of 
network providers may bill you for any amount greater than the payment made by the Plan to the provider.  
 
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 and the services are listed as covered, 
out of network providers may bill you for any amount greater than the payment made by the Plan to the 
provider. The record shows that the Plan paid the full amount based on the in network fee schedule (INFS).  
You are responsible for the difference between the INFS and dentists' charged fees when visi ting an out of 
network dentist. Therefore, we decided that the Plan does not have to pay more for the limited oral evaluation 
(D0140), the periapical x-ray (D0220), and 4 extractions (D7140) provided from August 11, 2020, to August 
20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you assumed the doctor obtained prior 
authorization. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided 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 by 
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0481 provided on September 8, 
2020. 
 
You asked the Plan to pay for the drug testing. 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 G0481 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the documentation does not 
support the prescriber's reasoning for the definitive drug testing requested. Specifically, why the enrollee would 
need 8-14 classes of drug tested, as well as their history, if there has been problems with abuse, or inconsistent 
screens was not provided. Based on this information, we decided that Medicare rules for coverage of the drug 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 
G0481 provided on September 8, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the long-term care in a skilled nursing facility (SNF) 
provided. 
 
You asked the Plan to pay for the SNF services. You say that the services which the enrollee required and 
received on the date of service are coverable under the Medicare Act. The Plan denied your request. The Plan 
says no skilled nursing or therapy services were needed or provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that the 
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the long-term care in a skilled nursing facility (SNF) provided.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing 
needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required 
to establish a maintenance program or to prevent deterioration of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on 
September 22, 2020. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that your coverage includes full 
mouth x-rays every five years. You also say that your previous full mouth x-ray was in 2015. The Plan denied 
your request. The Plan says this service is not a benefit under your dental plan. The Plan also says that this 
service is only covered once every 5 years if you purchase the optional dental rider, which you had not done. 
 
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 series of intraoral x-rays provided on September 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OFEV. 
 
You asked the Plan to pre-approve OFEV. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve OFEV.  
 
Benefits for OFEV 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: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ambulatory surgical center services 
provided on February 24, 2020. 
 
You asked the Plan to waive the coinsurance for ambulatory surgical center services. You say that you were not 
informed that the provider was out-of-network and 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for in-network ambulatory surgical center services and 50% coinsurance for out-of-network 
ambulatory surgical center services. 
 
You received ambulatory surgical center services from an out-of-network provider on February 24, 2020. 
Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The allowed 
amount is $171.84 and 50% of that is $85.92. Please note that the out-of-network charges are in your financial 
favor.   
 
You have been asked to pay $85.92 for ambulatory surgical center services. Ambulatory surgical center 
services fall within the outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 coinsurance for ambulatory 
surgical center services provided on February 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second magnetic resonance imaging (MRI), brain 
interpretation provided on October 16, 2020. 
 
You asked the Plan to pay for a second brain MRI (70661) interpretation. You say that the enrollee had 
multiple exams on this date of service. The Plan denied your request. The Plan says the submitted 
documentation supports one unit of service which was previously approved and paid for on October 28, 2020. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 70661 is not supported in the medical record. Specifically, the medical report submitted 
is a duplicate of the paid interpretation. Based on this information, we decided that Medicare rules for coverage 
of a second brain MRI (70661) interpretation have not been met. Therefore, we decided that the Plan does not 
have to pay for a second magnetic resonance imaging (MRI), brain interpretation provided on October 16, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive hearing test and audiologic function test 
provided on  
July 15, 2020. 
 
You asked the Plan to pay for the comprehensive hearing test and audiologic function test. The Plan denied 
your request. The Plan says you must receive your care from a network provider. In most cases, care you 
receive from an out-of-network provider will not be covered. If you need medical care that Medicare requires 
our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-
of-network provider. You, or your PCP, must obtain authorization from the plan prior to seeking 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 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 comprehensive hearing test and audiologic function test 
provided on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 1, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive your care from a network provider. In most cases, care you receive from an out-of-network provider 
will not be covered. If you need medical care that Medicare requires our plan to cover and the providers in our 
network cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, 
must obtain authorization from the plan prior to seeking 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physicians services. 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 services provided on May 1, 2020.