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

 
We decided that the Plan does not have to pay for the self-administered drugs provided from April 19, 2020 to 
April 20, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that these medications were administered 
while you were in the hospital. You also say that you were diagnosed with a mild heart attack, and were moved 
to inpatient to be observed. The Plan denied your request. The Plan says self-administered drugs are not 
covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from April 19, 2020 to April 20, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assisted living care provided on February 10, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for assisted living care. You say that it is the facility's responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the 
provider, facility or member. 
 
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 care provided on February 10, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (81599) rendered by the out of 
network (OON) provider on March 6, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service 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 this service. Therefore, we decided that the Plan does not 
have to pay for the laboratory service (81599) rendered by the out of network (OON) provider on March 6, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the onabotulinumtoxina injection (J0585) 
provided on March 18, 2020. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the service provided. 
 
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 in-network Preferred Medicare Part B covered drugs provided in a specialist?s office.  
 
You have been asked to pay $118.31 ($591.56 Plan allowed amount x 20% coinsurance) for the in-network 
Medicare Part B covered drug provided in a specialist?s office. 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 onabotulinumtoxina injection (J0585) provided on March 18, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bronchoscopy services coded 31624 provided on 
December 31, 2019. 
 
You asked the Plan to pay for the bronchoscopy services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 31624 is bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with bronchial alveolar lavage. 
 
We find that CPT code 31624 is not supported in the medical record. Specifically, the documentation submitted 
did not indicate that bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 
bronchial alveolar lavage was performed on the billed date of service. Based on this information, we decided 
that Medicare rules for coverage of the bronchoscopy services have not been met. Therefore, we decided that 
the Plan does not have to pay for the bronchoscopy services coded 31624 provided on December 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PET imaging from the skull to thigh (78815) provided on 
January 15, 2020. 
 
You asked the Plan to pay for the PET imaging. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says C50.919 is not listed as an acceptable diagnosis 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PET imaging have not been met. Specifically, the Medicare Claims Processing Manual, 
Chapter 13, 60.16 includes a list of appropriate diagnosis codes for PET procedures. The diagnosis code 
included on the claim, C50.919 is not listed as an appropriate diagnosis code. Therefore, we decided that the 
Plan does not have to pay for PET imaging from the skull to thigh (78815) provided on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish and adjunctive pre-
diagnostic test provided on January 21, 2020. 
 
You asked the Plan to pay for the topical application of fluoride varnish and adjunctive pre-diagnostic test. You 
say that these services were medically necessary. The Plan denied your request. The Plan says your plan does 
not cover these procedures. 
 
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 
topical application of fluoride varnish and adjunctive pre-diagnostic test provided on January 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight physical therapy (PT) visits. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says four visits are approve and eight further are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 these services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has been receiving PT for low back pain and lumbar 
radiculopathy. There is no documentation that the requested additional eight therapy visits are generally 
accepted as specific and effective therapy for the enrollee's condition. The four approved additional visits 
appear to be adequate to transition to a home exercise program. There is no documentation that the unique 
skills of a professional therapist are required to safely and effectively provide treatment, that the services can 
be safely and effectively performed only by a therapist or under the supervision of a therapist for the eight 
additional requested visits. The four approved additional visits appear to be adequate to transition to a home 
exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve eight physical therapy (PT) visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy and thigh lift. 
 
You asked the Plan to pre-approve panniculectomy. You say that you have an excess amount of skin which 
prevents you from moving normally. The Plan denied your request. The Plan says the denial of authorization 
for this service is correct, because the records do not show that your extra skin is causing issues or chronic 
infection. 
 
The Plan follows Medicare rules. Medicare rules say that panniculectomy surgery is only covered for the 
clinical conditions 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 panniculectomy. Our reviewer says that 
you do not meet the Medicare criteria for the requested surgery services. Our physician reviewer found your 
panniculus does not hang below the level of the pubis, and the medical records do not document chronic 
intertrigo that consistently recurs over 3 months while receiving appropriate medical therapy, or that it remains 
refractory to appropriate medical therapy over a period of 3 months. There is no evidence of chronic infection, 
inflammation, or ongoing necrosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a panniculectomy and thigh lift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a replacement battery (E2365) provided on March 16, 2020. 
 
You asked the Plan to pay for the replacement battery. You say that you would like reconsideration because 
there is not another supplier in the area within the Plan's network. The Plan denied your request. The Plan says 
payment cannot be made to a provider who does not accept Medicare payment. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the replacement battery have not been met. Specifically, the record indicates that Amazon.com is 
not eligible for Medicare assignment. Therefore, we decided that the Plan does not have to pay for a 
replacement battery (E2365) provided on March 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis, and complete 
series of intraoral x-rays provided on November 19, 2019 by an OON provider. 
 
You asked the Plan to pay more for the periodic oral evaluation, prophylaxis, and complete series of intraoral 
x-rays. You say that the Plan documents state that you should only pay after the Plan pays 50% for out-of-
network services. The Plan denied your request. The Plan says these services were rendered by a non-
participating provider. The Plan also says that you are responsible for 50% coinsurance as well as any excess 
amount not allowed by the 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 Plan is only obligated to pay 50% 
coinsurance of the allowed amount. When services are received OON, you are also responsible for the 
difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to 
pay more for the periodic oral evaluation, prophylaxis, and complete series of intraoral x-rays provided on 
November 19, 2019 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar spinal infusion and inpatient admission. 
 
You asked the Plan to pre-approve the surgery and inpatient admission. You say that you would like 
reconsideration because the member has had multiple back surgeries for herniated disc. The Plan denied your 
request. The Plan says the member does not meet medical necessity criteria for inpatient surgery. 
 
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 surgery and inpatient admission. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no documentation of lumbar instability, fracture, or tumor. 
There are no imaging studies showing severe stenosis or lumbar degenerative instability. 
 
 
 
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 surgery and inpatient admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve lumbar spinal infusion and inpatient admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient office visits (99213) manual electrical stimulation 
(97032) manual therapy (97140) acupuncture (97810) unlisted procedure (99070) provided December 6, 2019 
to June 23, 2020. 
 
You asked the Plan to pay for the outpatient office visits. You say that you are requesting that your actual 
expenses be credited towards your deductible and all subsequent office visits, chiropractic adjustments and 
electrical stimulation, once the deductible has been satisfied, to be reimbursed at the cash amount you paid for 
at $66.80 per visit. The Plan denied your request. The Plan says date of service 12/06/2019 processed with the 
correct 5% coinsurance. The services provided on dates 02/03/2020-02/24/2020 are not covered under the plan 
benefits. Claims for dates of services provided 03/02/2020-03/23/2020 are denied due to a coding error and 
claims for dates of services provided 04/20/2020 and 05/02/2020-05/24/2020 needs a corrected claim to be 
processed. 
 
The Plan must follow Medicare rules. 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 Medicare rules say that 
that acupuncture services are not covered by Medicare. Medicare rules also say that providers must report 
services correctly. Providers must report services with the appropriate CPT code. 
 
In this case, the health plan contract clearly says you must pay 5% coinsurance for each chiropractic specialists 
office visit. The acupuncture services provided 02/03/2020-02/24/2020 are not covered. Claims for dates of 
services provided 03/02/2020-03/23/2020 are denied due to a coding error and the provider needs to send 
corrected claims for dates of services provided 04/20/2020 and 05/02/2020-05/24/2020 to be processed. The 
plan had made multiple attempts to obtain the required corrected claims. Based on this information, we decided 
that Medicare rules for coverage of the outpatient office visits have not been met. Therefore, we decided that 
the Plan does not have to pay for outpatient office visits (99213) manual electrical stimulation (97032) manual 
therapy (97140) acupuncture (97810) unlisted procedure (99070) provided December 6, 2019 to June 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on March 2, 2020. 
 
You asked the Plan to pay for the core buildup. You say that according to your Evidence of Coverage, balance 
billing is not allowed. You also say that you did not have any desire to receive services that were not covered. 
The Plan denied your request. The Plan says this service is not covered by 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 core 
buildup, including any pins when required (D2950) provided on March 2, 2020.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different level of care. 
 
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 medical records provided the complexity of the enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee may require skilled physical therapy and occupational therapy but 
based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation 
therapy program. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BLS non-emergency ambulance service (A0428) and 
ground mileage (A0425) provided January 27, 2020. 
 
You asked the Plan to pay for the non-emergency ambulance service. You say that the attached claim has been 
submitted multiple times with all required information needed for processing. No payment has been received 
and the same information  that has been submitted continues to be requested. The Plan denied your request. 
The Plan says this claim is a duplicate of a previously submitted claim. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
Based on the documentation provided, the plan has already processed and paid $235.95 for this ambulance 
service on check dated February 28, 2020. There is no additional documentation showing that there were 2 
transports provided. Based on this information, we decided that Medicare rules for coverage of the non-
emergency ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for 
the BLS non-emergency ambulance service (A0428) and ground mileage (A0425) provided January 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 there is no evidence that the enrollee requires services that are not currently available. 
As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing LTC needs. 
 
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 long term acute care hospital (LTACH) services.