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

 
We decided that the Plan does not have to waive the copayment for specialist services provided on February 
12, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you disagree with the charges. 
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 $50 
copayment for specialist visits.  
 
You have been asked to pay a $50 copayment for specialist services. Specialist services fall within the 
physician/practitioner services, including doctor's office visits 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 specialist services provided on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out 
of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the enrollee was not allowed to travel to their doctor's 
appointments and feel that due to the circumstances the claim should be paid. 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 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 the medical services 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 podiatry visit you had on June 16, 2020. 
 
You asked the Plan to waive the copayment for the podiatry visit. You say that you should not have to pay this 
copayment because you were not satisfied with the service you received.  You said that the doctor only spent 8-
10 minutes with you. The Plan denied your request. The Plan says 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 $45 
copayment for podiatry services.  
 
You have been asked to pay a $45 copayment for the podiatry visit. This copayment applies regardless of 
whether you are satisfied with the visit. 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 podiatry 
visit you had on June 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tooth re-implantation (D7270), the limited oral evaluation 
(D0140), the initial periapical x-ray (D0220), 2 additional periapical x-rays (D0230) and to waive the 
coinsurance for the extraction (D7140) provided. 
 
You asked the Plan to pay for the dental services. You say that after your appointment, you 
passed out in the parking lot. You say that you were sent to the hospital due to your injuries. You also say that 
the services you received should be billed under medical services due to the way that it happened. The Plan 
denied your request. The Plan says the services you received are dental in nature. The Plan says the tooth re-
implantation is not listed as a covered service. The Plan says the frequency limit of 1 oral exam per calendar 
year has been exceeded. The Plan says the frequency limit of up to 4 individual periapical x-rays per year has 
been exceeded. The Plan also says that the extraction was processed correctly with the 50% coinsurance for 
comprehensive dental services.  
 
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 tooth re-implantation is not among 
those covered under this benefit. The record shows that the Plan paid for the oral exam that you received on 
April 19, 2020, thus exceeded the frequency limit of once per calendar year. The record shows the Plan paid for 
3 periapical x-rays you received and 1 thus exceeding 
the frequency limit of up to 4 per year. 
 
 
Additionally, although the extraction is listed as a covered service, there is a 50% coinsurance for 
comprehensive dental services. This is a contractual obligation you agreed to when you enrolled in the Plan?s 
dental coverage. Therefore, we decided that the Plan does not have to pay for the tooth re-implantation 
(D7270), the limited oral evaluation (D0140), the initial periapical x-ray (D0220), 2 additional periapical x-rays 
(D0230) and to waive the coinsurance for the extraction (D7140) provided from April 19, 2020, to May 13, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home ventilator, any type, used with non-invasive interface, 
(e.g., mask, chest shell) (CPT Code E0466) provided from June 26, 2019, through July 28, 2019. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not supported by the 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. 
 
Based on this information, we decided that Medicare rules for coverage of the DME have not been met. 
Healthcare Common Procedure Coding System (HCPCS) code E0466 -RR (1 Unit) remains not supported. The 
documentation submitted did not include an itemized shipping/billing invoice or proof of delivery to indicate 
the billed supply was dispensed. Of note, the submitted itemized delivery ticket indicate a home ventilator 
represented by the HCPCS code E0465, was dispensed. Therefore, the billed supply code cannot be verified.  It 
is noted that multiple attempts were made to contact the provider for additional information.  
 
Healthcare Common Procedure Coding System (HCPCS) code E0466 -RR (1 Unit) remains not supported. The 
documentation submitted did not include an itemized shipping/billing invoice or proof of delivery to indicate 
the billed supply was dispensed. Of note, the submitted itemized delivery ticket indicate a home ventilator 
represented by the HCPCS code E0465, was dispensed. Therefore, the billed supply code cannot be verified.  It 
is noted that multiple attempts were made to contact the provider for additional information. Therefore, we 
decided that the Plan does not have to pay for home ventilator, any type, used with non-invasive interface, 
(e.g., mask, chest shell) (CPT Code E0466) provided from June 26, 2019, through July 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 
14, 2020. 
 
You asked the Plan to pay for the physician's services. You say that  The Plan denied your request. The Plan 
says you 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 innetwork 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 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's services provided on April 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs device. 
 
You asked the Plan to pre-approve the CardioMEMs device. You say that the records provided support the 
need for the requested device. The Plan denied your request. The Plan says the current medical literature 
indicates that this service is considered experimental and investigational, as it is not identified as widely used 
and generally accepted for the proposed use as reported in nationally recognized peer-reviewed literature. 
 
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 CardioMEMs device. Our reviewer 
says that a CardioMEMs device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found, in this circumstance, therapy change based on data obtained from a CardioMEMs 
device has been demonstrated in only one trial to help reduce hospital readmission compared to standard 
medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the 
results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading 
authorities and is not recommended in current guidelines for the treatment of heart failure. The device should 
still be considered experimental or investigational. 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis provided on May 27, 2020. 
 
You asked the Plan to waive the copayment for arthrocentesis. You say that you feel that you should only owe 
20% coinsurance. 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 $300 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay the allowed amount of $246.45, which is less than the $300 copayment for 
arthrocentesis. Arthrocentesis falls within the outpatient surgery, including 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 May 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of extracranial arteries provided on April 15, 
2020 by an OON provider. 
 
You asked the Plan to pay for the duplex scan of extracranial arteries. You say that this service was part of the 
continuity of care, and was medically necessary. You also say that you were unaware that a referral was 
necessary to provide medically necessary care to an enrollee. The Plan denied your request. The Plan says the 
service was rendered by a non-participating provider, and were not referred by a network provider. The Plan 
also says that the service was not approved in advance. 
 
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 duplex scan of extracranial arteries provided 
on April 15, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on January 31, 
2020 by an OON provider. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that authorization was obtained 
for all services. The Plan denied your request. The Plan says the service was rendered by a non-participating 
provider. The Plan also says that 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 the psychiatric diagnostic evaluation provided on 
January 31, 2020 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 25, 2020 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 request 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 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 the medical services provided on June 25, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the extraction of tooth #2 provided on June 9, 2020. 
 
You asked the Plan to pay for the extraction. You say that you received a notice saying you were pre-approved 
for a tooth extraction. You also say you received a notice of denial of payment. The Plan denied your request. 
The Plan says that your benefit limit had been exceeded for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that the health plan must provide you with a clear and 
accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under 
your plan contract including applicable conditions and limitations and any other conditions associated with the 
use or receipt of the benefits.  
 
We looked at the file and Medicare rules. The contract states that 1 removal of erupted or exposed roots per 
tooth is covered per lifetime. The enrollee reasonably believed the extraction of tooth #2 would be covered, 
because the contract does not clearly state that extractions are limited to only one extraction per calendar year. 
Based on this information, we decided that Medicare rules for coverage of the extraction have been met. 
Therefore, we decided that the Plan has to pay for the extraction of tooth #2 provided on June 9, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received 
from January 31, 2020, to February 5, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that because your hand 
nerves were damaged by the hospital's phlebotomist, you feel as though you should not have to pay this 
copayment. The Plan denied your request. The Plan says 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 $245 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $245 copayment per day for the inpatient hospital services. This copayment 
applies even if you were not satisfied with the care you received. 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 inpatient hospital services you received from January 31, 2020, to February 5, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair accessory, headrest, cushioned, any type, 
including fixed mounting hardware, each (CPT Code E0955) and privacy flap-back options (K0108). 
 
You asked the Plan to pre-approve the items. You say that you are requesting review of denial of services. The 
Plan denied your request. The Plan says the items are not approved for coverage. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the items have not been met. E0995, Wheelchair Accessory, Calf 
Rest/Pad Replacements, is listed under Column II, and K0861 (Power Wheelchair Base Groups 3, 4, and 5 
(K0848-K0891)) is listed under Column I. Therefore, payment of E0995, Wheelchair Accessory, Calf 
Rest/Pad, is included in the initially approved K0861 code for the group 3 power wheelchair. A separate 
request for E0995 should be denied as unbundled. Furthermore, the Privacy Flap-Back (K0108) is not a 
medically necessary item. This item does not serve a medical purpose. Per Medicare rules, these items are not 
reasonable and necessary, and therefore, should not be covered. Therefore, we decided that the Plan does not 
have to pre-approve wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, 
each (CPT Code E0955) and privacy flap-back options (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the device interrogation services rendered on April 29, 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 procedure code 93297 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 93297 and 93295. Code 93297 is a column II code with a 
modifier indicator of 1 when billed with column I code 93295. Code 93297 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the device 
interrogation services rendered on April 29, 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 the patient appears to be unstable and requires additional acute care services to 
further stabilize which is likely to take 24 days or less based on recent notes. The patient does not require 
services at the LTACH that are not already available at the current facility. There are no services at the LTACH 
that the patient requires that are not already available and covered at the current facility. Therefore, this request 
for LTACH will be considered not medically necessary at this time. Transfer to a lower level of care may be 
considered with additional stabilization. 
 
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.