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

 
We decided that the Plan does not have to pay for the anesthesia services provided on July 10, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the anesthesia services. You say that you disagree with the plan's denial. The 
Plan denied your request. The Plan says the services received are not a covered benefit. 
 
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. Therefore, we decided that the Plan does not have to pay for the anesthesia services 
provided on July 10, 2020 by an out of network (OON) provider.  
 
We note that the plan has paid these services at the allowed amount. The plan has also noted they will notify 
the provider that they are unable to balance bill you. Therefore, the claim was processed correctly.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a physician visit provided on August 26, 2019. 
 
You asked the Plan to pay for physician visit. You say that you are appealing with proof of timely filing. The 
Plan denied your request. The Plan says that the denial of payment for this service is correct, because this claim 
was not submitted within the timely filing limit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later 
than one calendar year after the date of service. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide any evidence that this claim was submitted beyond the 
timely filing limit. Without this information, the Plan has not shown that its decision to deny payment for this 
claim is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for a 
physician visit provided on August 26, 2019.  
 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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. 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 the enrollee does not require the intensity of services provided at an IRF.  
 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), harness for 
upgrade to expandable controller (E2313), electronic connection between wheelchair controller and two or 
more power seating system motors (E2311), and an expandable controller (E2377). 
 
You asked the Plan to pre-approve a power seat elevation system, harness for upgrade to expandable controller, 
electronic connection between wheelchair controller and two or more power seating system motors, and an 
expandable controller. You say that the items are necessary. The Plan denied your request. The Plan says based 
on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair accessories are covered when specific 
criteria is met. 
 
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 a power seat elevation system, harness 
for upgrade to expandable controller, electronic connection between wheelchair controller and two or more 
power seating system motors, and an expandable controller. Our reviewer says that the items are not medically 
necessary. Our physician reviewer found the documentation does not reveal that the enrollee needs an 
expandable controller to operate other types of proportional input devices (e.g., mini-proportional or compact 
joysticks, touchpads, chin control, head control, etc.), non-proportional input devices (e.g., sip and puff, head 
array, etc.), or to operate 3 or more powered seating actuators through the drive control. The documentation 
does not reveal the enrollee needs the expandable controller to operate a separate display (i.e., for alternate 
control devices), other electronic devices (e.g., control of an augmentative speech device or computer through 
the chair's drive control), or for an attendant control. The enrollee has sufficient strength in the upper 
extremities and functional ability to operate any power options through their own individual switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power seat elevation system, harness for upgrade to expandable controller, 
electronic connection between wheelchair controller and two or more power seating system motors, and an 
expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power seat elevation system (E2300), harness for upgrade to expandable controller (E2313), electronic 
connection between wheelchair controller and two or more power seating system motors (E2311), and an 
expandable controller (E2377).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manipulation under anesthesia (MUA) of the spine and 
bilateral hip joints (22505, 27275)  provided July 2, 2020 to July 23, 2020. 
 
You asked the Plan to pay for the outpatient surgery. You say that please review all documentation to support 
medical necessity of the procedure codes 22505 and 27275. The Plan denied your request. The Plan says this 
service is experimental and investigational and is not covered. There is insufficient clinical evidence to support 
spinal MUA. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient surgery have not been met. Therefore, we decided that the Plan does not have to pay 
for manipulation under anesthesia (MUA) of the spine and bilateral hip joints (22505, 27275)  provided July 2, 
2020 to July 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dispensing fee binaural (V5160) and binaural behind the ear 
(V5140) provided on August 13, 2020. 
 
You asked the Plan to pay for binaural behind the ear and dispensing fee. You say that the service should be 
covered. The Plan denied your request. The Plan says there is no coverage if hearing aids or related services are 
received from a provider not part of the plans hearing aid vendors network and are not registered in advance. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for two 
hearing aids every two years when registered in advance.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of binaural behind the ear and dispensing fee have not been met. Specifically, you did not contact the 
Plans hearing department in advance to register and you received the item outside the Plan?s hearing aid 
vendors network. This means the service is not a covered benefit. Therefore, we decided that the Plan does not 
have to pay for dispensing fee binaural (V5160) and binaural behind the ear (V5140) provided on August 13, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant supported porcelain/ceramic crown (D6065) 
provided on May 7, 2020. 
 
You asked the Plan to pay for the implant supported crown. You say that the Plan documentation shows that 
there was coverage of a porcelain/ceramic crown in 2019 when you started the process, as well as in 2020. The 
Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. 
 
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 the 
implant supported porcelain/ceramic crown (D6065) provided on May 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 4, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the physician determined the services were 
medically necessary. The Plan denied your request. The Plan says the enrollee's plan requires utilization of 
network providers, and authorization for certain 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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services 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 lab services provided on October 4, 2019 by an out of network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower 
denture (D5214) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve a partial upper denture and a partial lower denture to be provided by an 
OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are 
in-network providers that are able to provide this care. Therefore, coverage criteria has 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 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 
a partial upper denture (D5213) and a partial lower denture (D5214) to be provided by an out of network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exams provided. 
 
You asked the Plan to waive the copayment for the eye exams. You say that you should not have copayments 
for eye exams. The Plan denied your request. The Plan says you were charged the copayments 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 $25 
copayment for all Medicare covered eye exams provided in-network. 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. 
 
You have been asked to pay a $25 copayment for each of the eye exams. The eye exams fall within the 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 the eye exams provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial lower denture (D5214) provided on February 5, 
2020. 
 
You asked the Plan to pay for the dental item. You say that the benefits highlights includes information about 
dental preventative services as well as dental comprehensive services. You say that you inquired about the 
difference between the two. You say that you were never advised that partial dentures were excluded. You also 
say that you were advised that preventive and comprehensive dental services would be covered up to $1,000. 
The Plan denied your request. The Plan says the lower partial denture is not listed as a covered service. The 
Plan also says that any services not listed are not covered. 
 
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 partial denture is not among those 
covered under this benefit. The record shows that the Plan provided information regarding general dental 
coverage and specifically a cleaning. Therefore, we decided that the Plan does not have to pay for the partial 
lower denture (D5214) provided on February 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 27, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 
laboratory 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 laboratory services provided on January 27, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99283) electrocardiogram, routine 
ECG with at least 12 leads (93005) radiologic examination, shoulder (73030) collection of venous blood by venipuncture 
(36415) shoulder orthosis (L3670) provided August 28, 2020 
 
You asked the Plan to pay for the emergency services. You say that the records provided should support the necessity of 
the service in dispute. The Plan denied your request. The Plan says this was a work related injury and is the liability of 
the workers compensation carrier 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an 
enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim 
for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the 
primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the 
bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary 
insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan is secondary to the 
worker?s compensation carrier. As the secondary insurer, the Plan cannot be held responsible for the emergency services 
until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay 
for the emergency department visit (99283) electrocardiogram, routine ECG with at least 12 leads (93005) radiologic 
examination, shoulder (73030) collection of venous blood by venipuncture (36415) shoulder orthosis (L3670) provided 
August 28, 2020
Appeal type: SNF
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for the 11th day of SNF care. We decided that the Plan 
does not have to waive the copayment for the first 10 days of SNF care of this billing period.  
 
You asked the Plan to waive the copayment for the SNF care. You say that you were not informed that your 
coverage was about to end. The Plan says that the copayment amount you are being charged is correct. 
 
We decided that the Plan has to waive the copayment for the 11th day of SNF care.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $0 copayment each day for days 1 to 20, $160 copayment 
each day for days 21 to 51, and $0 copayment for additional covered days up to 100 days per benefit for Skilled 
Nursing Facility care. This SNF period lasted 10 days, resulting in a copayment amount of $1,600. 
  
The Plan says you must pay a $1,760 copayment for SNF care. Based on the Plan contract, however, you 
cannot be asked to pay more than a $1,600 copayment for SNF care. Therefore, we decided that the Plan has to 
waive the copayment for the 11th day of SNF care.  
 
We also decided that the Plan does not have to waive the copayment for the first 10 days of SNF care of 
this billing period. 
 
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 $0 
copayment each day for days 1 to 20, a $160 copayment each day for days 21 to 51, and a $0 copayment for 
additional Medicare-covered days, up to 100 days for Skilled Nursing Facility (SNF) Care. This SNF stay 
lasted 10 days, resulting in a total copayment amount of $1,600. 
 
You have been asked to pay a $0 copayment each day for days 1 to 20, a $160 copayment each day for days 21 
to 51, and a $0 copayment for additional Medicare-covered days, up to 100 days for SNF care. SNF care falls 
within the Skilled Nursing Facility (SNF) Care 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 the first 10 days of SNF care of this billing period. 
 
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 the collagenase injection provided on July 
30, 2020. 
 
You asked the Plan to waive the coinsurance for the collagenase injection. You say that the doctor checked 
prior to treatment and said it would be covered by insurance. You say that you cannot afford to pay this. The 
Plan denied your request. The Plan says the coinsurance applied 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 20% 
coinsurance for each Medicare-covered service from an in-network provider. 
 
You have been asked to pay $912.60, which is 20% of the allowed amount for the collagenase injection. The 
allowed amount is $4,562.98 (20% x $4,562.98 = $912.60). The collagenase 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 
the collagenase injection provided on July 30, 2020.