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

 
We decided that the Plan has to pre-approve a referral to an endocrinologist. 
 
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 care can be managed by the PCP. 
 
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 services are considered medically reasonable and necessary in this case. Our physician reviewer 
found you have osteoporosis and hyperparathyroidism. You meet the criteria for endocrine referral at this time 
according to the provided guidelines for endocrine referral. Furthermore, you meet criteria for surgical referral 
since she has osteoporosis and hyperparathyroidism. 
 
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 referral to an endocrinologist.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on May 21, 
2020. 
 
You asked the Plan to pay for periodontal maintenance (D4910). You say that you went for a normal cleaning 
and wasn't aware they were doing something special that was not going to be covered. 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 pay for 
periodontal maintenance (D4910) provided on May 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 5, 2019 by an out of 
network provider. 
 
You asked the Plan to pay for the medical services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says you did not get prior authorization for out-of-network 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 the services provided on December 5, 2019 by an 
out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided April 19, 
2020. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that the items were medically necessary. 
The Plan denied your request. The Plan says rules for telehealth services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. The record does not show any effort by the prescribing physician to contact the 
enrollee's primary physician, nor does the record show an established relationship between the prescribing 
physician and the enrollee. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a neuromuscular stimulator 
(E0745) provided April 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapy services provided on February 11, 
2020. 
 
You asked the Plan to waive the copayment for the therapy services. You say that you should only have to pay 
one copayment for this date of service. The Plan denied your request. The Plan says you received both 
specialist services and therapy services, so two separate copayments apply. 
 
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 each therapy service and a $30 copayment for each specialist service. 
 
Records show that on the date of service in question, you received both an occupational therapy service as well 
as services related to lymphedema strapping with a specialist. You have been asked to pay both a $25 
copayment for the therapy service and a $30 for the specialty (i.e., lymphedema strapping) service. This means 
that you have been asked to pay the correct amounts 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 therapy services provided on February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections (67020, J2778) provided March 
17, 2020 to May 5, 2020. 
 
You asked the Plan to waive the coinsurance for the injections. You say that the coinsurance should be waived. 
The Plan denied your request. The Plan says the correct cost-sharing was applied up to the out-of-pocket 
maximum. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay a 20% coinsurance for the injections (up to the $899 maximum). The injections 
fall within the Part B 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 injections 
(67020, J2778) provided March 17, 2020 to May 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on November 26, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from 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 did not pre-approve the 
physician?s services. 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 physician's services provided on November 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 24, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the CPAP accessories. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this provider is out-of-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 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 May 24, 2020 by 
an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial observation care (99220) provided December 24, 
2019. 
 
You asked the Plan to pay for the initial observation care. You say that these services were significant, 
separately identifiable, medically necessary and fully documented. By all CPT global package policies there 
are separate services not subject to re-bundling. The Plan denied your request. The Plan says procedure code 
incidental to primary procedure. 
 
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 the 
initial observation care has a bundled relationship with code 99223 (Initial Hospital Care) and cannot be paid as 
billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for the initial observation care 
(99220) provided December 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from March 12, 2020 through March 19, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you are on a 
limited income and cannot afford this charge. The Plan denied your request. The Plan says your cost sharing 
obligation for inpatient services is the same whether or not you go to an in-network or out-of-network facility. 
The plan says that you were charged this copayment correctly. 
 
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 per day for days 1-4 for inpatient hospital services.  
 
You have been asked to pay a $450 copayment per day for days 1-4 for the inpatient hospital services (for a 
total of $1800). 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 inpatient hospital services you received 
from March 12, 2020 through March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 14, 2020. 
 
You asked the Plan to pay for the physician's services. 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 
physician's services. 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 physician's services provided on May 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on February 20, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that these tests were ordered by the referring provider. The 
Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring 
provider is also out-of-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 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 lab work provided on February 20, 2020 by an out 
of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided April 20, 
2020. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that the item was medically necessary. 
The Plan denied your request. The Plan says rules for telehealth were not met, therefore the item at issue cannot 
be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. The record shows no effort by the prescribing physician to contact the enrollee's 
physician. There was no physical exam or record of an established relationship between the enrollee and the 
prescribing physician. Consequently, the items/services ordered following the noncovered visit are likewise 
noncovered. Therefore, we decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) 
provided April 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on February 25, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for outpatient 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 outpatient services provided on February 25, 2020 
by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9500) provided on March 26, 2020 
through March 27, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was processed and paid 
correctly. 
 
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 find that CPT code S9500 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9500 has a status indicator of I. This means that CPT code S9500 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9500) 
provided on March 26, 2020 through March 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient behavioral health hospital stay provided on 
April 25, 2020 to April 29, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the inpatient behavioral health hospital stay. You say that please find additional 
supporting clinical documentation that supports continued acute psychiatric inpatient treatment through her 
discharge on 04/29/2020. The Plan denied your request. The Plan says enrollee's must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. The plan says that 
non-emergent services with non-contracted providers require prior authorization before services being 
rendered. 
 
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 at issue in this case is not a network provider with the Plan. 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 inpatient behavioral health hospital stay. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based upon review the records provided for the admission of this enrollee does not meet criteria for acute 
inpatient mental health treatment as she was not shown to be a danger to herself or others, auditory or visual 
hallucinations. She is noted to be cooperative and compliant with treatment while not showing any acute threat 
to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care rather than a lower level of care as she did not have dangerousness to self or others. 
 
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 inpatient behavioral health hospital stay have not been met.  
 
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 pay for the inpatient behavioral health hospital stay. Therefore, we 
decided that the Plan does not have to pay for the inpatient behavioral health hospital stay provided on April 
25, 2020 to April 29, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 3, 2020 to 
January 31, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment. 
 
We looked at the file and Medicare rules. The file shows that the claims were not billed with the correct TOB 
code. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
January 3, 2020 to January 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdomen x-ray rendered on March 15, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claims are duplicates. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the abdomen x-ray rendered on March 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on January 3, 2019 to January 
4, 2019. 
 
You asked the Plan to pay for the surgery services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are payable by Original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that any services associated with a clinical trial are 
paid through Original Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgery services have not been met. Therefore, we decided that the Plan does not have to pay 
for the surgery services provided on January 3, 2019 to January 4, 2019.