Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services coded 62324 provided on March 27, 
2020. 
 
You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 62324 is not supported in the medical record. Specifically, this service was billed with 
modifier LT (left side). Modifiers LT or RT are inappropriate for this procedure code. Based on this 
information, we decided that Medicare rules for coverage of the injection services have not been met. 
Therefore, we decided that the Plan does not have to pay for the injection services coded 62324 provided on 
March 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinical visit (G0463) provided on 
March, 2, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the hospital outpatient clinical visit. You say that you did not know prior 
authorization was required for this patient. The Plan denied your request. The Plan says prior authorization was 
not obtained as required under plan benefits. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinical visit (G0463) 
provided on March, 2, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 12, 2020. 
 
You asked the Plan to pay for the physician's 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 services provided on March 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on June 4, 2020. 
 
You asked the Plan to pay for the bitewing x-rays (D0274). You say that x-rays were taken, and the tooth could 
not be saved because it was cracked. You say that this was an emergency and should be paid. The Plan denied 
your request. The Plan says the service exceeds the frequency limitation in benefit 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, you also have a maximum benefit of 
one bitewing x-ray per plan year. The Plan paid for bitewing x-rays provided on January 9, 2020, which 
exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays 
(D0274) provided on June 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waivethe deductible charge for the diagnostic services you received on May 20, 2020.You asked the Plan to waivethe deductible. You say that you have never had to pay a deductible for vision services.The Plan denied your request. The Plan says this was a diagnostic test.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 $250 deductible before the Plan will cover its share for covered medical services. The service you asked the Plan to waive falls within the outpatient diagnostic tests benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible for these services. This cost sharing is a contractual obligation that had not been met at the time the services was received on May 20, 2020.Therefore, we decided that the Plan does not have to waivethe deductible charge for the diagnostic services you received on May 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rebase of the lower complete denture provided on June 
15, 2020. 
 
You asked the Plan to pay for the rebase of the lower complete denture. You say that you were assured 
insurance would cover the expenses. 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 pay for the rebase 
of the lower complete denture provided on June 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0120, D0274, D1110) provided by an out-
of-network dentist on June 2, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says dental services provided out-of-network are 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 pay for dental 
services (D0120, D0274, D1110) provided by an out-of-network dentist on June 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for medical equipment, supplies, and drugs 
provided during an outpatient hospital procedure (C1766, C1769, C1893, C1894, J1885, J1940, J2250, J3010) 
performed May 21, 2020 to May 22, 2020. 
 
You asked the Plan to waive the coinsurance for the items provided during the outpatient procedure. You say 
that you stayed overnight so the inpatient copayment should be applied instead. The Plan denied your request. 
The Plan says the correct coinsurance was applied for items and services provided in the outpatient setting. 
You were not admitted as an inpatient. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medical Equipment and supplies and Part B Drugs.  
 
You have been asked to pay a 20% coinsurance for the items provided during the outpatient procedure. The 
items provided during the outpatient procedure falls within the Medical Equipment and supplies and Part B 
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 coinsurance for medical equipment, supplies, 
and drugs provided during an outpatient hospital procedure (C1766, C1769, C1893, C1894, J1885, J1940, 
J2250, J3010) performed May 21, 2020 to May 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on June 3, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services provided were medically 
necessary. You say that you were initially take to an emergency room and then were transferred to the hospital 
in dispute for trauma, due to your diagnosis. The Plan denied your request. The Plan says the inpatient level of 
care was not medically necessary and that the services needed could have been provided at the observational 
level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found you were admitted to the hospital after a ground level fall outside of a restaurant 
parking lot. The exam showed a left eye periorbital ecchymosis, and ecchymosis over left facial area. There 
was no focal sensory or motor deficits. The imaging showed a non-displaced left inferior orbital fracture, left 
fifth displaced metacarpal fracture, and a non-displaced left maxilla facial fracture. Computed tomography of 
the brain was negative, an EKG was non-acute, and troponin normal. Maxillofacial surgery consults 
recommended observation only and no surgical interventions, as fractures are non-displaced. You were 
discharged home on June 4, 2020. The record did not show that, at the time of inpatient admission, the 
admitting physician reasonably expected that your necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on June 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 31, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 31, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and x-ray services provided on April 21, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit and x-ray services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit and x-ray services provided on 
April 21, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99202). 
 
You asked the Plan to waive the copayment for the office visit. You say that you received an email offering 
COVID testing. You were told that there will be no charge to you, not even a copay. The Plan denied your 
request. The Plan says the claim processed with the correct copayment applied for the office visit. No copay 
was applied to the coronavirus testing CPT code 87635. 
 
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 $30 
copay for Medicare covered physician specialist services. 
 
You have been asked to pay $30 copay for the office visit. The office visit falls within the 
Physician/Practitioner services, including doctor's office visits. 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 outpatient office visit.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay foran ambulance transport (A0428, A0425) provided May 11, 2020.You asked the Plan to pay forthe ambulance transport. You say that ambulance transportation was medically necessary.The Plan denied your request. The Plan says the transport was to a non-covered destination.The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.Therefore, we decided that the Plan does not have to pay foran ambulance transport (A0428, A0425) provided May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on February 20, 2020 by an out of network (OON)provider.You asked the Plan to pay foroffice visit. 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 provider is out-of-network with the Plan and 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 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 forthe medical services provided on February 20, 2020 by an out of network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve the medical services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services can be provided by an in-network provider. 
 
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 
the medical services to be provided by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your needs are custodial.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF 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 reviewerto 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 the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 the patient appears to be more stable but requires additional short-term acute care 
services (less than 25 days), which can be completed in the current setting. The patient does not require 
services at the LTACH that are not already available at the current setting. There are no services at the LTACH 
that the patient requires that are not already available and covered at the current hospital setting. Therefore, this 
request for LTACH services will be considered not medically necessary. Transfer to a lower level of care may 
be considered soon. 
 
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 LTACH services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (CPT Code 22869) and insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; second level (CPT Code 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not necessary. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the device is experimental. More research is needed to show the safety and efficacy of the 
device. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869) 
and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression 
or fusion, including image guidance when performed, lumbar; second level (CPT Code 22870).