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

We decided that the Plan does not have to pay for x-ray services provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider is out-of-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The 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 x-ray services provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the services are not a Medicare benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The testing at issue in this appeal was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on July 31, 2020. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says this provider is a 
participating provider with the Plan's medical vision services, but he is not a participating provider with the 
Plan's vision 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 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 
eye refraction. 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 an eye refraction provided on July 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 29, 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 29, 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 29, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 27, 2020. 
 
You asked the Plan to pay for the laboratory services. 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 
laboratory 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 laboratory services provided on July 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that it does not appear this member can actively participate in the intensive 
rehabilitation program provided in an IRF at this time. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require, or to be able to currently tolerate, fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met at a lower level of care. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision of excessive skin and subcutaneous tissue 
(15839) provided on November 18, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that reconstructive surgery for cosmetic 
purposes is not covered by Medicare. 
 
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 this service. Our reviewer says that the 
service provided is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical record does not provide information regarding the indication or need for the procedure. 
The medical reasonableness or necessity of the procedure as defined by Social Security Act Section 1862 
(a)1(A) and the 42 CFR Section 411.15(k) cannot be ascertained. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for the excision of excessive skin and subcutaneous tissue (15839) provided on November 18, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the muscle skin graft services coded 15734 and the injection 
services coded 64450 provided on April 2, 2020. 
 
You asked the Plan to pay for the muscle skin graft services and 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 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. 
 
We find that CPT codes 15734 and 64450 are not supported in the medical record. Specifically, the operative 
report does not include documentation of a muscle, myocutaneous, or fasciocutaneous flap, from the trunk; 
therefore, code 15734 cannot be verified. The operative report did not include documentation of anesthetic 
agent and/or steroid injection(s) into other peripheral nerve or branch; therefore, code 64450 cannot be verified.  
Based on this information, we decided that Medicare rules for coverage of the muscle skin graft services and 
the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the 
muscle skin graft services coded 15734 and the injection services coded 64450 provided on April 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance, half 
leg (E0673) provided August 3, 2020. 
 
You asked the Plan to pay for the pressure pneumatic appliance. You say that the records provided should 
support the medical necessity of the service in dispute. The Plan denied your request. The Plan says the only 
time that a segmented, calibrated gradient pneumatic compression device would be covered is when the 
individual has unique characteristics that prevent them from receiving satisfactory pneumatic compression 
treatment using a non-segmented device. 
 
The Plan follows Medicare rules. The rules state PCD related accessories are eligible for reimbursement only 
when the appropriate related base PCD's meets the applicable coverage criteria for the type of PCD. 
 
The file does not show that the enrollee was approved the appropriate related base PCD. Therefore, we decided 
that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance, half leg (E0673) 
provided August 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oral exam (D0120), the cleaning (D1110), and 
the bitewing x-rays (D0274) provided on October 7, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that the services you received in January 
were reimbursed. You say that if you were reimbursed in January, you should be reimbursed for these services 
too. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan 
also says that payment cannot be made for dental services that you receive from a provider who has opted out 
of Medicare. 
 
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, 
dental services that you receive from a provider who has opted out of Medicare will not be reimbursed. 
Additionally, the record shows that the Plan paid for the services in January 2020 in error. Therefore, we 
decided that the Plan does not have to reimburse you for the oral exam (D0120), the cleaning (D1110), and the 
bitewing x-rays (D0274) provided on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection provided by a participating provider.

You asked the Plan to waive the copayment for an injection. You say that you had to reschedule due to reasons out of your control and your original appointment was to be done in an office. The Plan denied your request. The Plan says the correct copayment has been 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 $450 copayment for outpatient surgery/in-network/outpatient hospital.

You have been asked to pay $304.17 which is less than your copayment amount of $450 for an injection. The injection you received is considered an outpatient surgery. These services were provided at a hospital facility; therefore, the correct copayment has been applied. An injection falls within the outpatient surgery/in-network/outpatient hospital 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 an injection provided by a participating provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring 
(95941) provided on January 17, 2019. 
 
You asked the Plan to pay for continuous intraoperative neurophysiology monitoring. You say that you would 
like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 
95941 has a status indicator of I and 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. 
 
We find that CPT code 95941 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 94951 has a status indicator of I. This means that CPT code 95941 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of continuous intraoperative 
neurophysiology monitoring have not been met. Therefore, we decided that the Plan does not have to pay for 
continuous intraoperative neurophysiology monitoring (95941) provided on January 17, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ambulance ride.

You asked the Plan to waive the deductible for the ambulance ride. You say that you should not be billed this since you have insurance and Medicare. You say you were told it was out-of-network and there was no in-network ambulance service. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

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 that applies towards out-of-network Medicare-covered ambulance services.

The ambulance ride you asked the Plan to waive the deductible for falls within the "Ambulance services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards each one-way out-of-network Medicare-covered ground ambulance service. This cost sharing is a contractual obligation that had not been met at the time the ambulance ride. Therefore, we decided that the Plan does not have to waive the deductible for the ambulance ride.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an electrocardiogram and health assessment (93000, 96160).

You asked the Plan to waive the copayment for the electrocardiogram and health assessment. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for diagnostic tests. 

You have been asked to pay the Medicare allowed amounts of $17.98 for the electrocardiogram and $2.65 for the health assessment, for a total of $20.63. This is less than the $30 copayment listed in the plan contract for diagnostic tests. 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 an electrocardiogram and health assessment (93000, 96160).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0120), cleaning (D1110), intraoral x-
rays (D0220), bitewing x-rays (D0274), resin-based composites (D2330, D2391) and endodontic therapy 
(D3310) provided on December 7, 2020 and December 8, 2020. 
 
You asked the Plan to pay for the dental services. You say that these services are listed as covered and this is an 
in-network provider. The Plan denied your request. The Plan says some of these services are not covered by 
Medicare or by the Plan's supplemental dental benefit. Some of the services provided are covered by the Plan's 
benefit, however the maximum frequency for these services was already exhausted earlier in the year. The Plan 
has also indicated that this provider is out-of-network, and therefore none of these services can be covered 
regardless because the Plan's supplemental dental benefit does not cover out-of-network services. 
 
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 
either not covered by this benefit or have exceeded the Plan's allowed frequency. The Plan provided 
documentation showing that you are enrolled in only the mandatory preventative benefit and were not enrolled 
in the additional optional supplemental dental coverage at the time of service. The mandatory benefit covers: 
one exam and cleaning once per year, one set of bitewing x-rays once per year, one full-mouth or panoramic x-
ray once every five years, and periapical x-rays and palliative (emergency) care as needed. Services are covered 
when provided by dentists who participate in the Plan's network. 
 
The Plan provided documentation that you received an oral evaluation (D0120) and a cleaning (D1110) in June 
of 2020. The Plan's supplemental benefit only covers one oral evaluation and one cleaning per year. On the 
date of service in question, this benefit had been exhausted for the year. Additionally, the resin-based 
composites (D2330, D2391) and endodontic therapy (D3310) are not covered by this benefit under any 
circumstances. 
Documentation was also provided that shows that this provider participates in a network that the Plan contract 
clearly states will not be covered. If you use a provider that is in this specific network or use a provider that 
does not participate with your supplemental dental Plan, you will be responsible for the full cost of those 
services and no payment will be made. 
 
Therefore, we decided that the Plan does not have to pay for the oral evaluation (D0120), cleaning (D1110), 
intraoral x-rays (D0220), bitewing x-rays (D0274), resin-based composites (D2330, D2391) and endodontic 
therapy (D3310) provided on December 7, 2020 and December 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on September 29, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered. 
 
We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on September 29, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot leave the hospital until you go into 
rehabilitation. You say that you are only using two liters of oxygen instead of five liters. The Plan denied your 
request. The Plan says based on Medicare guidelines, the IRF services do not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the documentation provided, it is my opinion that the health Plan's 
denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
care needs can be met at a lower level of care (ex. skilled nursing facility/subacute rehabilitation). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve an Orthovisc injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there was no x-ray or MRI of the left shoulder. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the injection. Our reviewer says that the 
requested injection is medically reasonable and necessary. Our physician reviewer found the enrollee has x-ray 
documented osteoarthritis of the left shoulder that has not responded to simple analgesic therapy. In this case, 
the requested agent is being used for its Food and Drug Administration approved indication. The requested 
agent is safe and effective and medically reasonable and necessary. The elements of the controlling coverage 
rules are satisfied.  The requested service is recommended. 
 
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 injection have been met. Therefore, we decided that the Plan has to pre-
approve an Orthovisc injection for the enrollee.  
 
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.