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

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on February 18, 2020 
and billed under codes 80157, 80177, 80201, 80162, 80159 and 80173. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not support that this testing was performed with blood 
sampling.  Blood specimen collection is by venipuncture; however, the lab requisition does not state the 
specimen collected for the billed code; therefore, the billed service cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted cannot be paid due 
to an issue with the type of specimen reported. Medicare billing criteria were not met. Therefore, we decided 
that the Plan does not have to pay for lab services provided to the enrollee on February 18, 2020 and billed 
under codes 80157, 80177, 80201, 80162, 80159 and 80173.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on October 28, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim has not been processed by the primary insurance.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer.However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed that a different Plan was the primary insurer for the date of service at issue and the claim has not been processed by the primary insurer. As the secondary insurer, the Plan cannot be held responsible for these services untilthe primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on October 28, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns (D2740) for teeth # 7, 8, 9 and 10. 
 
You asked the Plan to pre-approve the dental services. You say that you believe that you need the crowns for 
teeth # 7, 8, 9 and 10 replaced. You say that the previous crowns are 7 to 8 years old. You say that they are 
chipped and cracked. You also say that while brushing your teeth, you can feel that something may have 
happened on the inside of the crown. The Plan denied your request. The Plan says that the provided 
documentation does not support your request for new crowns. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says 
that the requested crowns are medically necessary. Our physician reviewer found the provided documentation 
indicates that the current crowns are greater than 5 years old. The reviewer found that the current crowns are ill 
fitting, have recurrent caries and have cracks. Therefore, the reviewer found that the requested crowns are 
medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve crowns (D2740) for teeth # 7, 8, 9 and 10.  
 
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: DME/ Orthotics
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 the prosthesis. You say that you would like reconsideration because the 
materials used by the network provider negatively affect your quality of life. The Plan denied your request. The 
Plan says this equipment can be supplied 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out of network (OON) provider.  
 
Your complaint about the quality of equipment is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc right knee injections. 
 
You asked the Plan to pre-approve Orthovisc injections (J7324). You say that you want the enrollee treated 
with this drug. The Plan denied your request. The Plan says the enrollee has not first tried and had a 
contraindication or intolerance to Synvisc or Euflexxa. 
 
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 Orthovisc (J7324). Our reviewer says 
that the drug is not reasonable and medically necessary. Our physician reviewer found based on the medical 
records provided the enrollee has not tried and failed the required drug. There is no indication that the Plan's 
required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc (J7324) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Orthovisc knee injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network vision physician services provided on June 8, 
2020.  
 
You asked the Plan to pay for this service. You say that the Plan should cover this visit. The Plan denied your 
request. The Plan says this provider is out of network and these were not urgent or emergent services. 
 
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. Limited point of service benefits out of network are available 
with prior authorization and under specific circumstances.  
 
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 service 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 out of network vision physician services provided on June 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe unlisted ambulance service (A0999) provided April 3, 2020.You asked the Plan to pay forthe unlisted ambulance service. You say that you are appealing CPT code A0999 which was billed for the utilization of personal protective equipment and decontamination of the ambulance during and after ambulance services were provided to the enrollee.The Plan denied your request. The Plan says procedure code A0999 is not active and therefore is not covered by Medicare.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 we have confirmed that code A0999 is an invalid/inactive code. This code cannot be paid as a separate line item. Based on this information, we decided that Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forthe unlisted ambulance service (A0999) provided April 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup. 
 
You asked the Plan to pre-approve the backup. You say that you are in hurricane season, and the power 
systems are very unstable. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
A battery backup cannot be covered as it is considered duplicative. Therefore, we decided that the Plan does 
not have to pre-approve a battery backup.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DME provided. 
 
You asked the Plan to pay for the DME. 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 
DME. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the 
Plan does not have to pay for DME provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on March 3, 2020 and 
billed under codes 80157, 80177, 80201, 80162, 80159, and 80173. 
 
You asked the Plan to pay for these lab services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says the documentation submitted did not support that the denied codes 
were performed with blood sampling.  Blood specimen collection is by venipuncture; however, the lab 
requisition does not state the specimen type collected for the billed code; therefore, the billed service cannot be 
verified 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted cannot be paid due 
to a discrepancy regarding the type of specimen collected. Medicare billing criteria were not met. Therefore, 
we decided that the Plan does not have to pay for lab services provided to the enrollee on March 3, 2020 and 
billed under codes 80157, 80177, 80201, 80162, 80159, and 80173.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network outpatient mental health care provided to the 
enrollee from February 13, 2020 to June 12, 2020. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 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 out of network outpatient 
mental health care provided to the enrollee from February 13, 2020 to June 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup. 
 
You asked the Plan to pre-approve core buildup. You say that it is imperative that the tooth be restored with 
full coverage to maintain function. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the $55 cost share (50% coinsurance) for outpatient therapy 
services provided on March 5, 2020 and March 26, 2020. 
 
You asked the Plan to waive this cost share. You say that you do not believe this coinsurance is correct. The 
Plan denied your request. The Plan says this coinsurance was charged based on the services provided and the 
Plan contract agreement. 
 
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 50% 
coinsurance for outpatient therapy.  
 
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 $55 cost share (50% coinsurance) for outpatient therapy services provided on March 
5, 2020 and March 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an out of network eye exam provided on June 25, 2020. 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says you did not have prior authorization for 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 an out of network eye exam provided on June 25, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided, the health plan?s denial of LTACH coverage 
should be upheld. The patient is currently undergoing treatment at an ACH for chronic obstructive pulmonary 
disease (COPD). The patient is not intubated/ventilated. There is no evidence that the patient requires services 
that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is 
no advantage in transferring the patient to the LTACH. The patient can remain at the current ACH until such 
time no acute services are required. The patient can then be transferred/discharged to a lower level of care for 
any ongoing LTC needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe alcohol and/or other drug treatment program with CPT code H2036 provided on March 30, 2020.You asked the Plan to pay forCPT code H2036. 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 as 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.We looked at the file and Medicare rules. In this case, CPT code H2036 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Based on this information, we decided that Medicare rules for coverage of CPT code H2036 have not been met.Therefore, we decided that the Plan does not have to pay forthe alcohol and/or other drug treatment program with CPT code H2036 provided on March 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan has to pay for the Emergency room, surgery and other outpatient services provided on 
January 30, 2020 and January 31, 2020. 
 
You asked the Plan to pay for the Emergency room, surgery and other outpatient services. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested 
services are not medically necessary. 
 
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 pay for the Emergency room, surgery and other 
outpatient services. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee has a history of hypertension who 
presented to the ER on January 30, 2020 with bilateral temporal pain and jaw claudication. The enrollee denied 
any history of temporal arteritis or TMJ. The enrollee was evaluated and started on oral Prednisone. The 
enrollee underwent temporal artery biopsies. The documentation supports that the enrollee met criteria for the 
services rendered. 
 
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 Emergency room, surgery and other outpatient services have been met. 
Therefore, we decided that the Plan has to pay for the Emergency room, surgery and other outpatient services 
provided on January 30, 2020 and January 31, 2020.  
 
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 waive the copayment forurgently needed services provided on June 30, 2020.You asked the Plan to waive the copayment forurgently needed services. You say that you feel that you should have been referred to the emergency room in the first place.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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for urgently needed services. You have been asked to pay a $45 copayment for urgently needed services. Urgently needed services fall within the urgently needed 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 forurgently needed services provided on June 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 very heavy duty power wheelchair (K0863). 
 
You asked the Plan to pre-approve a group 3 very heavy duty power wheelchair (K0863). You say that you 
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for the requested group 3 very heavy duty power wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 very heavy duty power wheelchair (K0863).