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

 
We decided that the Plan does not have to pay for the office visit (99213), arthrocentesis (20600, 20610), and 
the triamcinolone acetonide injection (J3301) rendered by the out of network (OON) provider on June 8, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. 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 the office visit (99213), arthrocentesis (20600, 20610), and the triamcinolone 
acetonide injection (J3301) rendered by the out of network (OON) provider on June 8, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the emergency room (ER) services you 
received on October 17, 2019, March 11, 2020, and March 22, 2020. 
 
You asked the Plan to waive the copayments for the ER services. You say that you received conflicting bills 
from the hospital. The Plan denied your request. The Plan says it has confirmed with the hospital that you are 
only responsible for a $90 ER copayment for each date of service. The plan stated that the hospital confirmed 
that there was a billing error on your statements, but you only owe the copayments. 
 
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 $90 
copayment for emergency room services.  
 
You have been asked to pay a $90 copayment for each of the ER services. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayments for the emergency room (ER) services you received on October 17, 2019, March 11, 
2020, and March 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation, prophylaxis, and 
bitewings provided on February 28, 2020 by an OON provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, prophylaxis, and bitewings. You say that the 
provider's office told you they were in network, but set you up with a provider that was not in network. You 
also say that this office is listed in the Plan's network book. The Plan denied your request. The Plan says you 
saw a dentist outside of the Plan's network. The Plan also says that you are responsible for the difference 
between the dentist's fees, and the Plan's dental fee schedule. 
 
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 are responsible for the difference 
between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan 
does not have to pay for the comprehensive oral evaluation, prophylaxis, and bitewings provided on February 
28, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 18, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for cognitive assessment visit. You say that your doctor has no control over the 
facility's protocol and relies on the facility to obtain proper authorization. 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 for the medical services provided on February 18, 
2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for medical supplies provided a participating 
provider on January 4, 2020 to May 4, 2020. 
 
You asked the Plan to waive the coinsurance for medical supplies. You say that you were quoted this amount 
for a three-month supply. You say that you are now being charged that amount monthly. The Plan denied your 
request. The Plan says the correct coinsurance 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay less than a 20% coinsurance of the allowed amount for medical supplies. The total 
allowed amount is $1,676. The total amount you are being asked to pay is $167.60 which is less than your 20% 
coinsurance amount of $335.20 ($1,676 x 20% = $335.20). Medical supplies fall within the durable medical 
equipment 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 supplies provided 
by a participating provider on January 4, 2020 to May 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-on-
network provider on June 4, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 has network providers 
available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-on-network provider 
on June 4, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing provided on August 19, 2019. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the denial of payment for this service is correct, because the 
documentation submitted does not support the code billed. 
 
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; qualitative or quantitative, all sources, includes specimen validity 
testing, per day; 8 to 14 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is supported in the medical record. Specifically, the record support definitive 
drug testing for 8 to 14 drug classes, including metabolites. Based on this information, we decided that 
Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for 
drug testing provided on August 19, 2019.  
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dermatology services provided on January 24, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for dermatology services. You say that you would like this claim reprocessed and 
paid. 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 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 dermatology services provided on January 24, 
2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental surgery procedure (41899) rendered by the out of 
network (OON) provider on March 23, 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 the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the dental surgery procedure (41899) rendered by the out of network (OON) provider on  
March 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gold foil restoration provided on February 28, 2020. 
 
You asked the Plan to pay for the gold foil restoration. You say that the provider's office told you that the cost 
for a regular filling and the gold foil filling were the same. You also say that you were not told that your plan 
does not cover gold foil fillings. The Plan denied your request. The Plan says this procedure is not a benefit 
under your dental 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, the requested items or services are not 
among those covered under this benefit. The only restorations that are covered are amalgam or resin 
restorations. Therefore, we decided that the Plan does not have to pay for the gold foil restoration provided on 
February 28, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99310) 
rendered by the out of network (OON) provider on October 1, 2019. 
 
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 the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care, per day (99310) rendered by the out of network (OON) 
provider on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist telehealth services provided by a 
participating provider on April 15, 2020. 
 
You asked the Plan to waive the copayment for specialist telehealth services. You say that you should not have 
to pay for a phone call. 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 $45 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $45 copayment for specialist telehealth services. Specialist telehealth services 
fall within the physician/practitioner services/specialist 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 specialist telehealth services provided by a participating provider on April 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for discharge day management (99239) provided on March 13, 
2020. 
 
You asked the Plan to pay for discharge day management. You say that this was medically necessary. The Plan 
denied your request. The Plan says this code is not supported. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the medical records do not 
contain documentation that 31 minutes or more were spent on this service. Based on this information, we 
decided that Medicare rules for coverage of discharge day management have not been met. Therefore, we 
decided that the Plan does not have to pay for discharge day management (99239) provided on March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery and non-radiological 
diagnostic services provided by a participating provider on February 13, 2020. 
 
You asked the Plan to waive the copayment for an injection and non-radiological diagnostic services. You say 
that these injections are for muscle pain and not cosmetic. You say that these services shouldn't be denied. The 
Plan denied your request. The Plan says these services were not denied. The Plan says that the correct 
copayments have 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 $260 
copayment for hospital outpatient facilities/surgical center and a $25 copayment for outpatient diagnostic 
tests/in-network/non-radiological diagnostic services.  
 
You have been asked to pay a $260 copayment for an injection and a $25 copayment for non-radiological 
diagnostic services. The total amount you are being asked to pay is $285 ($260 + $25 = $285). An injection 
falls within the hospital outpatient facilities/surgical center benefit category and non-radiological diagnostic 
services falls within the outpatient diagnostic tests/in-network/non-radiological diagnostic services 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 outpatient surgery and non-radiological 
diagnostic services provided by a participating provider on February 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power scooter (K0800) purchased on March 3, 2020 from 
Heavenly Wheels. 
 
You asked the Plan to pay for a power scooter. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was purchased from a provider that does not participate in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The provider you purchased this item from is not enrolled in the 
Medicare program. Based on this information, we decided that Medicare rules for coverage of a power scooter 
have not been met. Therefore, we decided that the Plan does not have to pay for a power scooter (K0800) 
purchased on March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature. 
 
You asked the Plan to pre-approve power seat elevation feature. You say that the enrollee needs this wheelchair 
with accessories. The Plan denied your request. The Plan says the denial of authorization for this item is 
correct, because a power seat elevation feature is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation system is not covered by 
Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation feature have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power seat elevation feature.
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 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 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical record 
supports a need for physical and occupational therapy but it does not support a need for an intensive 
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 pre-approve a low dose computed tomography scan (LDCT) for lung 
cancer screening. 
 
You asked the Plan to pre-approve a LDCT scan for lung cancer screening. 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. Medicare rules say that lung cancer screening with LDCT is covered 
when all criteria is met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a LDCT scan for lung cancer screening have not been met. Specifically, the enrollee is not between 
the age of 55 and 77 years old. Therefore, we decided that the Plan does not have to pre-approve a low dose 
computed tomography scan (LDCT) for lung cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foot massager. 
 
You asked the Plan to pre-approve the massager. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a foot massager.