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

 
We decided that the Plan does not have to pay for the medical services provided by an 
OON provider. 
 
You asked the Plan to pay for an eye exam with refraction and ophthalmic diagnostic imaging. You say that 
you did not know that the enrollee needed a preauthorization to be seen. The Plan denied your request. The 
Plan says rules for payment have not been met. 
 
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 by an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a tertiary-level referral for an orthopedic consultation. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this can be approved in-network. 
 
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 the referral. Our reviewer says that the 
requested referral is considered medically reasonable and necessary in this case. Our physician reviewer found 
you present with recent onset of acute low back pain. Current radiographs and imaging have documented 
progression of multilevel thoracic and lumbar compression fractures, with 50% height loss. You have been 
diagnosed with osteogenesis imperfecta. You have a history of 24 fractures, requiring multiple surgeries. You 
were previously followed by a tertiary pediatric center but had aged out. Under consideration is a request for 
orthopedic office consultation and follow-up visits at a tertiary care center. Your medical and surgical history, 
current symptomatology, and imaging findings support referral for orthopedic management. Orthopedic 
treatment at a tertiary level center is supported based on your young age and significant medical history 
requiring continuation of specialized orthopedic treatment. Therefore, this request for orthopedic office 
consultation and follow-up visits at a tertiary care center is medically reasonable and 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 referral have been met. Therefore, we decided that the Plan has to pre-
approve a tertiary-level referral for an orthopedic consultation.  
 
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 a group 2 standard power wheelchair for the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not indicate a mobility impairment. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found based on the 
medical records provided, there is no documentation that the enrollee has a personal mobility deficit that 
impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and 
bathing in customary locations within the home. Records indicate he is able to walk around the house but not 
long trips; he wants to go to the park. There is no documentation that the deficit cannot be helped by the use of 
a walker, cane, or manual wheelchair. There is no documentation that the enrollee could safely operate a power 
a mobility device. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 2 standard power wheelchair for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transforaminal lumbar/sacral steroid injection for the 
enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records received did not provide the imaging and/or scan test with the enrollee's 
records. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the lack of a recent physical exam and imaging fails to meet the criteria. The request is deemed not 
medically reasonable or necessary at this point. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transforaminal lumbar/sacral steroid injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (x2) (D6740) and a pontic (x3) 
(D6245). 
 
You asked the Plan to pre-approve the crowns and pontics. You say that the dental services are medically 
necessary. The Plan denied your request. The Plan says the benefit for these services has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the benefits for the requested services 
have been exhausted with services performed on July 23, 2020. Therefore, we decided that the Plan does not 
have to pre-approve a retainer crown (x2) (D6740) and a pontic (x3) (D6245).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis provided on June 29, 2020. 
 
You asked the Plan to waive the copayment for arthrocentesis. You say that you disagree with the charges 
because you did not receive a surgery and were in your doctor's office. 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 $450 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. 
 
The record shows that you received arthrocentesis on June 29, 2020, at an outpatient hospital facility. 
Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the 
allowed amount of $400.70, which is less than the $450 copayment.   
 
You have been asked to pay $400.70 for arthrocentesis. Arthrocentesis falls within the outpatient surgery and 
other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 arthrocentesis provided on June 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy visits. 
 
 
 
You asked the Plan to pre-approve the additional physical therapy visits. You say that the additional visits are 
medically necessary. The Plan denied your request. The Plan says 6 more visits have been approved, however 6 
additional visits are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Physical Therapy is covered when 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 the additional physical therapy visits. 
Our reviewer says that the additional therapy visits are not medically necessary. Our physician reviewer found 
the enrollee has been authorized additional sessions to review an independent exercise program. The  
specialized skill, knowledge and judgment of a qualified therapist is not further required to establish, design 
and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 
 
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 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 6 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for presbyopia correcting function of intraocular lens (IOL) 
(V2788) provided on July 20, 2020 and July 27, 2020. 
 
You asked the Plan to pay for presbyopia correcting function of intraocular lens. You say that the service 
should be covered. The Plan denied your request. The Plan says you are responsible for payment of that portion 
of the charge for the presbyopia-correcting IOL and associated services that exceed the charge for insertion of a 
conventional IOL following cataract surgery. 
 
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. The Plan covers these services when insertion of a conventional IOL is used following cataract 
surgery. 
 
We looked at the file and the Plan's rules. Per Medicare guidelines, procedure code V2788 is not covered by 
Medicare standards as it is a presbyopia-correcting IOL and Medicare only covers a conventional IOL 
following cataract surgery. The cost of the conventional IOL is included in the surgical procedure code 
(66984). Based on this information, we decided that the Plan's rules for coverage of presbyopia correcting 
function of intraocular lens have not been met. Therefore, we decided that the Plan does not have to pay for 
presbyopia correcting function of intraocular lens (IOL) (V2788) provided on July 20, 2020 and July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assisted living services provided by an out 
of network (OON) provider. 
 
You asked the Plan to pay for assisted living services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 assisted living services provided by an out of 
network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation services provided on April 18, 2020. 
 
You asked the Plan to pay for the transportation services. You say that the records provided support the 
transportation services in dispute. The Plan denied your request. The Plan says the services I dispute should be 
billed under Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 18, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for transportation 
services provided on April 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve a neurology evaluation. You say that you would approval for these services 
to be provided out-of-network. The Plan denied your request. The Plan says there are in-network providers 
available. 
 
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 
specialist 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 drug testing services provided to the enrollee on June 3, 2020 
and billed under codes G0483 and 80307. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the records provided do not contain a valid physicians order. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and when necessary provide medical records to 
substantiate the services billed. In this case, the records provided lack valid physician orders. Medicare rules 
for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for 
drug testing services provided to the enrollee on June 3, 2020 and billed under codes G0483 and 80307.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you would like approval to see this 
provider. The Plan denied your request. The Plan says there are in-network providers available. 
 
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 
specialist services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist services provided on June 26, 
2020. 
 
You asked the Plan to waive the copayment for the specialist services. You say that since you were not told you 
were going to be billed you should not have to pay for an office visit. You state it was not even a tele-doc visit. 
The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 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 medical record for the June 26, 2020, visit notes, ?telemedicine encounter to discuss Myrbetriq trial.?  
Additionally, under ?4.  Others.  Notes: This is a telemedicine visit requested and authorized by the patient due 
to a national state of emergency and a state mandated quarantine due to Covid-19 pandemic. Patient voiced an 
understanding of the current situation and consented to a telemedicine visit. This encounter was during the 
COVID 19 pandemic disaster response conditions. During a disaster, the provision of care is subject to the 
Crisis Standards of Care." Therefore, you are asked to pay a $50 copayment for the services. Your EOC states, 
"enrollees must pay a $50 copayment for each specialist visit for Medicare-covered services. Covered services 
include: Brief virtual (for example, via telephone or video chat) 5-10 minute check-ins with your doctor if you 
are an established patient and the virtual check-in is not related to an office visit within the previous 7 days, nor 
leads to an office visit within the next 24 hours or soonest available appointment, if offered by your provider." 
 
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the specialist services provided on June 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file 
and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-
approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and 
necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided, 
that the health plan?s denial should be upheld. You do not require the intensity of services provided at an IRF. 
Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. Your care needs can be met at a lower level of care. 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 IRF admission 
and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on July 7, 2020 by an out of network 
provider. 
 
You asked the Plan to pay for the home visit (99343). You say that the service was urgent and did not need 
authorization. The Plan denied your request. The Plan says the enrollee had ear pain and could have been seen 
at a lower level of 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 services at issue in this appeal. The Plan did not pre-approve the service at issue. 
The service was not urgent or emergent and was not authorized. 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 home visit 
provided on July 7, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 7. 
 
You asked the Plan to pre-approve the dental service. You say that the enrollee's previous crown on tooth # 7 
had broken off. You say that the enrollee was not experiencing any pain as a result. You also say that core build 
up and a crown are necessary. The Plan denied your request. The Plan says 1 crown per tooth, every 60 
months. The Plan says that the frequency limit has been exceeded. 
 
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 frequency limit of 1 crown per 
tooth every 60 months has been exceeded. The record shows that the enrollee received a crown for tooth # 7 on 
August 13, 2019, less than 60 months ago. Therefore, we decided that the Plan does not have to pre-approve a 
crown (D2740) for tooth # 7.