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

 
We decided that the Plan does not have to waive the copayment for an x-ray of the upper extremities (73000) 
provided February 5, 2020. 
 
You asked the Plan to waive the copayment for the x-ray. You say that the copayment should be waived. The 
Plan denied your request. The Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for radiology services.  
 
You have been asked to pay a $25 copayment for the x-ray. The x-ray falls within the radiology 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 x-ray of the upper extremities 
(73000) provided February 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical placement of implant body: endosteal implant
(D6010) provided on September 7, 2019.
You asked the Plan to pay for the dental services. You say that a sinus augmentation was done because your
bone is protruding outside of your gum level, the bone needed to be cut otherwise it will grow and then you
will have problems eating. You state that you only want to appeal the medical claim on file with the plan and
not the denied dental claim. The Plan denied your request. The Plan says the denied service was not in a result
of a direct accident. The Plan states the provider is a non-participating general dentist, and the service
performed in dental oral surgery.
Medicare generally does not cover dental services. The Plan follows the same rule.
The dental service reported is eligible only if it is a direct result of an accident. The reported service would not
be performed in conjunction with an accidental injury. Therefore, no payment can be made for this service. The
services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your
teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for
by Medicare. Therefore, we decided that the Plan does not have to pay for surgical placement of implant body:
endosteal implant (D6010) provided on September 7, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on August 8, 2019. 
 
You asked the Plan to pay for the drug testing. You say that the codes are supported by the physicians custom 
profile. The Plan denied your request. The Plan says the documentation did not include a valid physician order 
or medical records. 
 
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 G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. In this case, there is insufficient 
records that show the testing was needed to identify specific substances that were inadequately detected by a 
presumptive drug test. There is no evidence that shows the test was individualized to identify 22 or more 
specific non-prescribed medications or illicit substances. The records provided do not document concerns 
based on clinical review and judgement. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the definitive drug testing provided on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on September 25, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that these services were provided in good faith in an 
assisted living facility. The Plan denied your request. The Plan says prior authorization was not obtained for 
these 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. 
 
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 physician services provided on September 25, 
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services you received from November 25, 
2019, to December 30, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you are responsible for 
the cost share. 
 
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 each Medicare-covered chiropractic visit.  
 
Review of the file shows that you had eight Medicare-covered chiropractic visits from December 2, 2019, to 
December 30, 2019. You have been asked to pay a $20 copayment for each visit, totaling $160. These services 
fall within the chiropractic 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. 
 
The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation.  
 
The records show that the services (CPT 99203) you received on November 25, 2019 were not manual 
manipulation of the spine. These services are not covered and you are responsible for the full billed amount for 
these services. Therefore, we decided that the Plan does not have to pay for the chiropractic services you 
received from November 25, 2019, to December 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided on March 24, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you were never told that the provider was out-of-network. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
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. Review of the file show that you received extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided on March 24, 2020 by an out-of-network provider. For code D7210, the provider billed the plan $375.30. The allowed amount for the service is $138.00, and the plan paid $69.00. You are responsible for all fees in excess of the allowed amount, $306.30 ($375.30 - $69.00). The $306.30 which was assessed as your out-of-network liability is correct. Your EOC states, "you pay 50% coinsurance (You may be billed more by an out-of-network provider if the charge is greater than MAC) for extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210)." Therefore, we decided that the Plan does not have to pay for extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided on March 24, 2020 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tertiary level referral for weight management. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show the medical necessity for a tertiary level of care. 
 
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 referral. Our reviewer says that the 
requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation to show that tertiary care is medically necessary for weight management. The 
enrollee can seek treatment within Plan. The review has determined that the enrollee's condition does not 
require the highly specialized technical level of care that a tertiary referral provides. 
 
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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tertiary level referral for weight management.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for admission to an inpatient hospital for the enrollee.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan
denied your request. The Plan says that treatment can happen in a lower level of care, such as outpatient
treatment.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the staff at the hospital called on 7/30/2020 for more treatment to be certified. They requested
more inpatient treatment to begin 7/30/2020. She had been certified inpatient treatment from 6/1/2020 to
7/29/2020. The review indicates that the record showed that at the time of inpatient admission the admitting
physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or
observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for admission to an inpatient hospital for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Prolia injection provided on February 24, 2020.
You asked the Plan to waive the coinsurance for a Prolia injection. You say that you disagree with the charges and would not have received the injection if you had known that you would owe that much. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Prolia injection on February 24, 2020. The allowed mount is $1,099.20 and 20% of that is $219.84. You have been asked to pay the total coinsurance amount of $219.84 for a Prolia injection. A Prolia injection falls within the Medicare Part B prescription drugs 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 a Prolia injection provided on February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear purchased on February 25, 2020. 
 
You asked the Plan to pay for the eyewear. You say that this is your first eyewear purchase for the plan year. 
The Plan denied your request. The Plan says mail your request for payment together with any bills or receipts. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the eyewear have not been met. Your reimbursement off $150.00 for the eyewear cannot be paid to 
the provider. You may request reimbursement separately with the Member Reimbursement Form with 
supporting documentation of bills or receipts. Therefore, we decided that the Plan does not have to pay for the 
eyewear purchased on February 25, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from December 
24, 2019 to January 17, 2020. 
 
You asked the Plan to pay for SNF care. You say that this was the only facility that would accept the enrollee. 
The Plan denied your request. The Plan says this was non-covered respite care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that daily 
skilled services were not necessary. Our physician reviewer found rom a nursing perspective, the beneficiary 
received oral medications. The beneficiary had stable vital signs. He was alert with confusion and intermittent 
agitation, requiring redirection. He had routine foley catheter care. Regarding rehabilitation services, the 
beneficiary did not have documentation that he received nor required skilled therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from December 24, 2019 to January 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient behavioral health.
You asked the Plan to pre-approve inpatient behavioral health. 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 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 inpatient behavioral health. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found based upon review of the records provided, the enrollee does not meet criteria
for acute inpatient mental health treatment as she was not shown to be a danger to herself or others. She was
not experiencing auditory or visual hallucinations. She is noted to be cooperative and compliant with treatment
while not showing any acute threat to safety.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient behavioral health have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient behavioral health.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination sit to stand frame/table system (E0637) 
and accessories (E1399). 
 
You asked the Plan to pre-approve a combination sit to stand frame/table system and accessories. You say that 
this should be covered. The Plan denied your request. The Plan says this is a convenience item 
 
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 combination sit to stand frame/table system (E0637) and 
accessories (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided at the in-network 
benefit level by an out-of-network provider. 
 
You asked the Plan to pre-approve neurosurgery services. You say that this is the only provider you know of 
that works on your condition, and you have been told that he knows what he is doing. You also say that it 
would be of great important to you financially if you did not have to pay cost-sharing at the out-of-network 
benefit level for this treatment. The Plan denied your request. The Plan says the denial of authorization for 
coverage at the in-network benefit level is correct, because this provider is out-of-network with the Plan, you 
can be treated by an in-network provider, and you may elect to use your Point-of-Service (POS) benefits to see 
this provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees may choose to receive care for certain covered services from out-of-network providers 
by using the Plan's Point-of-Service (POS) benefits. 
 
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 at the in-network benefit level. You may choose to see this 
provider using your Point-of-Service (POS) benefits. Therefore, we decided that the Plan does not have to pre-
approve medical services to be provided at the in-network benefit level by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on November 15, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for psychiatric evaluation. You say that your provider depends upon the facility to 
verify eligibility and obtain 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 the nursing facility is also 
out-of-network with 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 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 November 15, 
2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve standing frame/table system, mobile (dynamic stander), 
any size including pediatric (E0642). 
 
You asked the Plan to pre-approve the item. You say that the item is medically necessary. The Plan denied your 
request. The Plan says Medicare does not consider standing tables to be primarily medical in nature. 
 
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 standing frame/table system, mobile (dynamic stander), any 
size including pediatric (E0642).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided to the enrollee from 
August 1, 2019 through August 31, 2019. 
 
You asked the Plan to waive the copayment for SNF care. You say that you believe the member has met their 
out-of-pocket for the plan year 2019. The Plan denied your request. The Plan says the claim was processed 
accordingly with the member's 2019 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
The member has a combined out-of-pocket amount of $1350 in which the member did not meet at time of 
service. For August 1, 2019 through August 31, 2019 the provider billed the plan for SNF care, $12,245.00 and 
the plan paid $0.00. The Medicare allowable is $600.00 and the plan assessed the copayment of $50 copayment 
X 12 days = $600 for member responsibility. We are upholding the $600 copayment assessed for SNF care as it 
was applied correctly according to the member's plan benefits. This means that the enrollee has been asked to 
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for SNF care provided to the enrollee from August 1, 2019 through August 31, 2019.