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

 
We decided that the Plan does not have to pay for physician's services provided on January 7, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee 
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 
physician's 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 January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for physician services and lab work provided 
by a participating provider on February 10, 2020, to February 27, 2020. 
 
You asked the Plan to waive the deductible for physician services and lab work. You say that you cannot afford 
this copayment during this difficult time. The Plan denied your request. The Plan says the correct deductible 
amount 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 $198 deductible for plan has a deductible.  
 
The item or service you asked the Plan to waive the deductible for Medicare Part B services. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible for plan has a 
deductible. This cost sharing is a contractual obligation that had not been met at the time physician services and 
lab work was received on February 10, 2020 to February 27, 2020. The total amount you are being asked to pay 
is $135.30. Therefore, we decided that the Plan does not have to waive the deductible for physician services 
and lab work provided by a participating provider on February 10, 2020, to February 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the denture. You say that the upper denture is medically necessary. The Plan 
denied your request. The Plan says your benefit for this item has been exhausted. 
 
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 record shows a complete upper 
denture has been provided on May 23, 2017. A complete upper denture is covered once every 60 months. Your 
benefit for this item has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a 
complete upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on June 11, 2020. 
 
You asked the Plan to pay for the anesthesia 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 
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 anesthesia services provided on June 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician telephone patient service (99443) provided on 
May 1, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the physician telephone patient service. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 physician telephone patient service (99443) 
provided on May 1, 2020, by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services (99285) 
provided from February 7, 2020, through February 8, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $120 
copayment for emergency care received in an emergency room.  
 
You have been asked to pay a $120 copayment for the emergency care provided in an emergency room. 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 emergency room services (99285) provided from 
February 7, 2020, through February 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasounds (76641 x 2, LT, RT) 
provided on June 1, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $110 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a 
physician's office or at a free-standing facility (such as a radiology center or medical clinic).   
 
You have been asked to pay $187.72 ($93.86 copayment x 2 tests) for the Medicare-covered radiological 
diagnostic services provided. This is the Plan allowed amount for these services, which is less than the 
applicable copayments. 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 breast ultrasounds  
(76641 x 2, LT, RT) provided on June 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the multianalyte assay procedure (81599) provided on April 
27, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the multianalyte assay procedure. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 multianalyte assay procedure (81599) provided 
on April 27, 2020, by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic radiology services provided by a 
participating provider on June 15, 2020. 
 
You asked the Plan to waive the copayment for an ECG. You say that you do not agree with this copayment. 
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 $200 
copayment for outpatient diagnostic tests/diagnostic radiology.  
 
You have been asked to pay $39.91 which is less than your copayment amount of $200 for an ECG. An ECG 
falls within the outpatient diagnostic tests/diagnostic radiology 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 diagnostic radiology services provided by a participating provider on June 15, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive drug tests (80307) and definitive drug tests 
(G0481) provided on June 22, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for drug tests. You say that you do not have the ability to determine whether these 
services require prior authorization from insurance plans. The Plan denied your request. The Plan says prior 
authorization must be obtained for non-emergent services by an out-of-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 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 presumptive drug tests (80307) and definitive 
drug tests (G0481) provided on June 22, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services on January 9, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were feeling better after the medics 
arrived. 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 January 9, 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 on January 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injections (J7323). 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the information 
submitted does not meet the Plan's medical necessity guidelines for coverage. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
criteria for Euflexxa has not been met. Our physician reviewer found there is no documentation of a trial of 
Orthovisc or Monovisc. Our reviewer also found that recent literature shows that viscosupplementation does 
not work well for treatment of degenerative joint disease knee pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa injections (J7323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) 
provided to the enrollee on June 17, 2020. 
 
You asked the Plan to pay for the orthosis. 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 rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a 
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary 
and conducted a face-to-face assessment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the durable medical equipment have not been met. Specifically, medical records do not support a 
prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an 
appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was 
performed. 
 
 
 
 
 
 
The information submitted does not confirm that Medicare coverage criteria have been met. Therefore, we 
decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided 
to the enrollee on June 17, 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. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the 
medical records provided you do not require treatment in an intensive rehabilitation therapy program. 
 
 
 
 
 
 
 
 
 
 
 
 
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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram interpretation (93010) provided June 1, 
2020. 
 
You asked the Plan to pay for the electrocardiogram interpretation. You say that the service was medically 
necessary. The Plan denied your request. The Plan says the CPT code billed is not supported by the records 
provided. 
 
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 93010 is not supported in the medical record. Specifically, a complete written report of 
the EKG interpretation was not provided. Payment for a simple EKG review is included in payment for the 
Emergency Room services. Based on this information, we decided that Medicare rules for coverage of the 
electrocardiogram interpretation have not been met. Therefore, we decided that the Plan does not have to pay 
for an electrocardiogram interpretation (93010) provided June 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a POC, rental (CPT Code E1392). 
 
You asked the Plan to pre-approve the POC. You say that the tanks provided by the Plan are too heavy due to 
your chronic back pain. The Plan denied your request. The Plan says they do not cover duplicate or redundant 
DME such as oxygen device when the second item performs the same function as the one currently provided to 
the enrollee. The Plan states there is no medical indication for you to receive a portable oxygen concentrator. 
The Plan states you currently have a standard oxygen delivery system which is an oxygen concentrator and a 
home fill compressor system for your in-home needs and portable oxygen cylinders. 
 
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 POC. Our physician reviewer found 
coverage criteria for a POC are not met. You have interstitial lung disease and are on supplemental oxygen. 
You have portable oxygen tanks, and is requesting a POC because the tanks are too heavy for walking and 
traveling outside the home. Medicare covers portable oxygen systems for mobility within the home. Additional 
systems for travel outside the home are not covered, as they are considered a convenience. Duplicate portable 
oxygen systems are not covered. A POC is not medically necessary, and the denial is upheld. 
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 POC have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a POC, rental (CPT Code E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent 
deep vein thrombosis. The Plan denied your request. The Plan says PCDs billed by E0675 are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. PCDs billed by E0675 are not 
covered. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0675).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit provided on January 14, 2020. 
 
You asked the Plan to pay for the office visit. You say that the enrollee presented to the office requesting to 
establish medical care. The Plan denied your request. The Plan says the services were rendered by an OON 
provider, out of area, without a prior authorization. The Plan also says that there was no referral from the 
enrollee's primary care physician. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
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 office visit. Our reviewer says that the 
service was not medically necessary. Our physician reviewer found the enrollee could have foreseen requiring 
the services prior to leaving his service area. Our reviewer found that the records did not indicate that the care 
provided was medically necessary. Our physician reviewer also found that it would have been medically 
reasonable to delay service until the enrollee returned to his/her service area or disenrolled from the health plan 
after April 30, 2020. 

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 office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for the outpatient office visit provided on January 14, 2020.