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

 
We decided that the Plan does not have to waive the deductible for vision care provided on July 23, 2020. 
 
You asked the Plan to waive the deductible for vision care. You say that you feel that you are being balance 
billed and you should only owe a $45 copayment. The Plan denied your request. The Plan says the claims were 
processed correctly, and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $400 deductible for vision care.  
 
You received vision care on July 23, 2020. The record shows that you had only paid $56.72 toward the $400 
deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of 
$243.50.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category vision care. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 deductible for 
vision care. This cost sharing is a contractual obligation that had not been met at the time vision care was 
received on July 23, 2020. Therefore, we decided that the Plan does not have to waive the deductible for vision 
care provided on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on September 3, 2020, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 services provided on September 3, 
2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tertiary care services. 
 
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says this is not 
medically 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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has a history of breast and lung cancer. The tertiary care services have been requested 
for the comfort of the enrollee are not medically necessary.
 
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 tertiary care services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided on May 
12, 2020. 
 
You asked the Plan to pay for the services provided. You say that the medical records support the billing of the 
procedures. The Plan denied your request. The Plan says the diagnosis code is not valid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code G0453 is continuous intraoperative neurophysiology 
monitoring. We find that the submitted medical record should support the use of the selected diagnosis code. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided on May 12, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elbow ulnar nerve neuroplasty (64718) and the wrist 
endoscopy surgery (29848) provided on April 5, 2019. 
 
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 are not payable as the claim was 
submitted untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until July 14, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the elbow ulnar nerve neuroplasty (64718) and the wrist endoscopy surgery 
(29848) provided on April 5, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 13, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that 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.  
 
We looked at the file and Medicare rules. The documentation submitted does not show that the services in 
question were provided in the emergency department, therefore it is inappropriate to bill with POS 23. 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 pay for the services provided on December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided from March 30, 2020, to July 6, 
2020. 
 
You asked the Plan to pay for the physician services. You say that you are not on the LEIE from OIG for 
Medicare exclusion. The Plan denied your request. The Plan says you are excluded or debarred from 
participation in State and Federal health care programs. 
 
The Plan must follow Medicare rules. Medicare rules say that if someone is on the LEIE they are not allowed 
to receive reimbursement for providing Medicare and Medicaid services in any capacity even if they are on this 
listing by the Med-QUEST Division.  
 
We looked at the file and Medicare rules. This provider is not federally sanctioned. Based on this information, 
we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we 
decided that the Plan does not have to pay for physician services provided from March 30, 2020, to July 6, 
2020.
Appeal type: Testing
Decision: Unfavorable

. 
 
We decided that the Plan does not have to waive the cost share for the stress test, the myocardial perfusion 
imaging, the medical supply, and the Part B drug provided on July 21, 2020. 
 
You asked the Plan to waive the cost share for the stress test, the myocardial perfusion imaging, the medical 
supply, and the Part B drug. You say that you do not owe the $226.18 amount. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for in-network Medicare-covered non-radiological diagnostic services, a $110 copayment for each 
in-network Medicare-covered radiological diagnostic service, 20% coinsurance for each in-network Medicare-
covered medical supply, and a 20% coinsurance for each in-network Medicare-covered Part B drug.  
 
 
You have been asked to pay total of $226.18 for the stress test, the myocardial perfusion imaging, the medical 
supply, and the Part B drug. The stress test, the myocardial perfusion imaging, and the medical supply fall 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies? benefit category. The Part B 
drug falls within the in-network Medicare-covered non-radiological diagnostic services; each in-network 
Medicare-covered Medicare Part B Prescription Drugs? benefit category. See chart below. 
 
Date of Service Service Allowed Amount Copayment/Coinsurance Member 
Liability 
July 21, 2020 Stress test $31.31 $20 $20 
July 21, 2020 Myocardial 
perfusion imaging 
$442.25 $110 $110 
July 21, 2020 Medical supply $243.40 20% $48.68 
July 21, 2020 Part B drug $237.48 20% $47.50 
Total    $226.18 
 
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 cost share for the stress test, the myocardial perfusion imaging, the medical 
supply, and the Part B drug provided on July 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic pill dispenser. 
 
You asked the Plan to pre-approve the item. You say that this should be covered. The Plan denied your request. 
The Plan says this is not a covered piece of durable medical equipment. 
 
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 an automatic pill dispenser.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pre-approve transcranial magnetic stimulation. 
 
You asked the Plan to pre-approve transcranial magnetic stimulation. You say that you need this treatment. The 
Plan denied your request. The Plan says that this has not been proven effective for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 transcranial magnetic stimulation. Our 
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the records provided, you meet the clinical criteria for the use of TMS 
therapy as you have tried pharmacologic agents and psychotherapy without success. There is no mention of you 
having a referral for electroconvulsive therapy. You have undergone extensive medication trials with 
antidepressants with no benefit and have undergone psychotherapy since 2016. The record shows that you have 
an indication for the requested Transcranial Magnetic Stimulation (TMS). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transcranial magnetic stimulation have been met. Therefore, we decided that the 
Plan has to pre-approve transcranial magnetic stimulation.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pregabalin. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pregabalin.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on May 19, 2020. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from May 19, 
2020 to May 20, 2020. The Plan says, per Medicare guidelines, the provider should bill Original Medicare for 
the services provided on May 19, 2020. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the physician services provided on May 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve out of network providers. You say that you prefer the requested provided 
because this is not just a routine hernia operation. The Plan denied your request. The Plan says it is understood 
this is not a routine procedure, however this service can be provided in 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 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service in question. We found no exception that would require the Plan to pre-approve out 
of network providers. Therefore, we decided that the Plan does not have to pre-approve the medical services to 
be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 5, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that the laboratory services are not supported in the medical record. Specifically, the documentation 
submitted did not support that the laboratory testing was performed with blood sampling. The lab requisition 
shows a urine sample was collected. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on March 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an esophagogastroduodenoscopy represented by code 43257 
and billed for date of service June 9, 2020. 
 
You asked the Plan to pay for the esophagogastroduodenoscopy. You say that the attached procedure note 
supports the charges. You say that the claim should be reprocessed, and payment should be made based on the 
MPFS of 2020. The Plan denied your request. The Plan says the code in dispute is statutorily non-covered. 
 
The Plan must follow Medicare rules. In order to be covered and reimbursed, an item or service must meet 
several requirements. It must fall within a defined benefit category, it cannot be excluded from coverage, either 
by statute or policy, and it must be medically reasonable and necessary. In the absence of a NCD, discretion 
may be used to establish medical policy, currently known as LCDs and LCAs. The purpose of these LCDs and 
LCAs is to create a working list of services and procedures that have been evaluated by the Medical Policy 
staff, who have determined that the services listed do not meet the reasonable and necessary criteria as defined 
in Section 1862 (a)(1)(A) of the Social Security Act. LCDs and LCAs are based on the strongest evidence 
available. The Medicare contractor has provided a list of services that it does not deem medically reasonable 
and necessary. 43257 is present on that list  
 
The contractor responsible for Medicare coverage in the State of Kansas, has determined that this service does not meet the criteria to be considered medically reasonable and necessary. Currently, this procedure is considered non-covered due to the fact that current peer-reviewed literature does not support the efficacy of the services. The LCA states that claims for this code will be denied as 'not proven effective.' Therefore, we decided that the Plan does not have to pay for an esophagogastroduodenoscopy represented by code 43257 and billed for date of service June 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited dental exam with dental code D0140 provided on 
September 17, 2020. 
 
You asked the Plan to pay for dental code D0140. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says dental code D0140 is limited to one procedure 
per plan year. The Plan says that dental code D0140 was previously received on date of service July 16, 2020, 
and the claim processed and paid on July 23, 2020. The Plan says, therefore, dental code D0140 for date of 
service September 17, 2020 will remain denied. 
 
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. 
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a limited dental 
exam with dental code D0140 on September 17, 2020. The Plan's contract says that you are covered for this 
service once every plan year. The file also shows that the Plan already paid for this service when you received 
it on July 16, 2020. Therefore, we decided that the Plan does not have to pay for the limited dental exam with 
dental code D0140 provided on September 17, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is a need for new imaging studies. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee's condition appears to have worsened recently despite therapy. Further therapy at this point 
does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional 
status until further medical assessment and treatment is pursued. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve physical therapy for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out of network 
provider. 
 
You asked the Plan to pre-approve outpatient surgery with an out of network provider. You say that you want 
this out of network doctor to perform the repair surgery. The Plan denied your request. The Plan says they have 
in network providers who can provide this service. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve medical 
services to be provided by an out of network provider.