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

 
We decided that the Plan does not have to pay for an x-ray provided on August 14, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for an x-ray. You say that this is a portable x-ray service. You say that you would 
like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not 
obtained. The Plan says that the member's primary care physician did not refer these 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 an x-ray provided on August 14, 2020 by an out of 
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on August 31, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this service was a 
standard office visit for a sore tooth. The Plan denied your request. The Plan says this service exceeds the 
frequency limitation in your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on March 30, 2020, and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Privigen. 
 
You asked the Plan to pre-approve Privigen. You say that the enrollee has been receiving gammaglobulin for 
the past 2 years with considerable improvement. The Plan denied your request. The Plan says coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We looked at the file and the rules. In this case, there was insufficient information to show that the requested 
drug is medically necessary. Therefore, we decided that the Plan does not have to pre-approve Privigen.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on May 29, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this service is not allowable because incorrect billing was identified for the code billed 
on date of service May 29, 2020. The date of service on the claim does not match the medical 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. In this case, there is a discrepancy in the records 
between the date of service and the dates on the claim. Medicare billing criteria are not met. Therefore, we 
decided that the Plan does not have to pay for lab services provided to the enrollee on May 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 29, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and paid. The 
Plan denied your request. The Plan says prior authorization is required for these services. The Plan says that the 
member's primary care physician did not refer these 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 lab services provided on June 29, 2020 by an out 
of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic treatment provided from December 16, 2019, 
through January 27, 2020. 
 
You asked the Plan to pay for the chiropractic treatment. 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 
chiropractic treatment. 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 chiropractic treatment provided from December 16, 2019, 
through January 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on July 2, 2020. 
 
You asked the Plan to waive the copayment for an EGD. You say that you disagree with the charges because 
you feel that it should be included in the colonoscopy screening. 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 $375 
copayment for outpatient surgery and other medical services provided at ambulatory surgical centers.  
 
You received an EGD on July 2, 2020. An EGD is considered a diagnostic procedure, not preventative. 
Therefore, you are responsible to pay the $375 copayment.  
 
You have been asked to pay a $375 copayment for an EGD. An EGD falls within the outpatient surgery and 
other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an EGD provided on July 2, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided from March 1, 2020, to 
March 7, 2020. 
 
You asked the Plan to waive the copayment for SNF care. You say that a few days prior to February 29, 2020 
you were told that your insurance was running out and your last covered day would be February 29, 2020. You 
also say that after you received the bill you spoke with a Plan representative who advised you to ignore the bill. 
The Plan denied your request. The Plan says the copayment amount you are being charged is correct. 
 
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 $0 
copayment per day for days 1 to 20 and $178 copayment per day for days 21 to 100 for Skilled nursing facility 
(SNF) care. This SNF stay lasted 6 days, resulting in a total copayment amount of $1,068. 
 
You have been asked to pay a $0 copayment per day for days 1 to 20 and a $178 copayment per day for days 
21 to 100 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 SNF care provided from March 1, 2020, to March 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on August 31, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were not aware 
that there was a limit to this service of 1 per year. The Plan denied your request. The Plan says this service 
exceeds the Plan's frequency maximum. 
 
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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on June 30, 2020, and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on August 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, first hour (99291) provided May 27, 2020. 
 
You asked the Plan to pay for the critical care services. You say that resubmitted the claim with the medical 
record. Please review for payment. The Plan denied your request. The Plan says the records do not support the 
service billed. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injures patient, first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted 
do not include a critical care progress note to include the time spent in critical care for the billed date of 
service. The records show that multiple attempts were made to obtain the additional information from the 
provider. Based on this information, we decided that Medicare rules for coverage of the critical care services 
have not been met. Therefore, we decided that the Plan does not have to pay for critical care, first hour (99291) 
provided May 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $50 copayment for ambulance transport provided on June 
3, 2020. 
 
You asked the Plan to waive this copayment. You say that the Plan should cover this ambulance care. The Plan 
denied your request. The Plan says this claim was covered in full minus the $50 contractual copayment. 
 
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 ambulance transport. 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 $50 copayment for ambulance transport 
provided on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for remote monitoring provided from July 11, 
2019, to September 12, 2019. 
 
You asked the Plan to waive the copayments for remote monitoring. You say that you disagree with the charges 
for the device because you were not informed of the copayments. 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 $35 
copayment for specialist visits. 
 
You received remote monitoring from July 11, 2019, to September 12, 2019, for a total of 3 specialist services. 
Therefore, you are responsible to pay a $35 copayment per each remote monitoring service. The total amount 
you owe is: $105.   
 
You have been asked to pay the total copayment amount of $105 for remote monitoring. Remote monitoring 
falls 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 copayments for remote monitoring provided from July 11, 2019, to September 12, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial preventive physical examination services identified 
with code G0402 received on July 23, 2020. 
 
You asked the Plan to pay for the initial preventive physical examination services. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers a one-time initial preventive 
physical exam (Welcome to Medicare physical exam) if you get it within the first 12 months of the effective 
date of your Medicare Part B coverage. 
 
We looked at the file and Medicare rules. Review of the file shows that you became effective with Medicare 
starting on November 1, 2015. More than 12 months had passed since you became effective with Medicare. 
Based on this information, we decided that Medicare rules for coverage of the initial preventive physical 
examination services have not been met. Therefore, we decided that the Plan does not have to pay for the initial 
preventive physical examination services identified with code G0402 received on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 3, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you are 
responsible for paying the full cost of services that aren?t covered by our plan, either because they are not plan 
covered services, or they were obtained out-of-network and were not authorized. 
 
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 September 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system, seat/back cushion, 
electronic connection, safety belt, expandable controller with harness, custom foot plate, custom mount 
brackets, and a foot plate hinge for a power wheelchair (PWC). 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that PWC accessories are covered when specific 
criteria are met and when requested under the correct coding.  
 
We looked at the file and Medicare rules. The requested services are a power seat elevation system, seat/back 
cushion, electronic connection, safety belt, expandable controller with harness, custom foot plate, custom 
mount brackets, and a foot plate hinge. 
 
The power seat elevation system is denied by Medicare as non-covered because it does not serve a purpose that 
is primarily medical in nature. The safety belt is not covered because it is already included in the approved 
PWC basic equipment package. The custom foot plate is not covered because it was not requested with the 
correct coding. The correct code K0041. The custom mounting is not covered because it is included in the 
already approved leg rests (E1012). The expandable controller and harness with electronic connection are not 
covered because the documentation does not show that the power options need to be controlled through a 
joystick. The power options can be controlled using the included switches. The replacement seat cover is not 
approved because the approved E2622 cushion already comes with a cover.  
 
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 a power seat elevation system, seat/back 
cushion, electronic connection, safety belt, expandable controller with harness, custom foot plate, custom 
mount brackets, and a foot plate hinge for a power wheelchair (PWC).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ultrasounds provided on July 15, 2020. 
 
You asked the Plan to waive the copayments for the ultrasounds. You say that you have never had to pay for 
this service before. You say you cannot afford the copayments. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing 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 $110 
copayment for each in-network Medicare-covered radiological diagnostic service, not including x-rays, 
performed in a physician's office or at a free-standing facility (such as a radiology center or medical center). 
For this date of service, you have been asked to pay the allowed amount of the claim because this amount is 
less than the $110 copayment for each of the ultrasounds. 
 
You have been asked to pay a $105.18 copayment for each of the ultrasounds. The ultrasounds fall within the 
?Outpatient Diagnostic Tests and Therapeutic Services and Supplies? 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 copayments for the ultrasounds provided on July 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 11, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for these services 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 on August 11, 2020 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure reducing air mattress. 
 
You asked the Plan to pre-approve the mattress. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records submitted do not support the criteria needed to qualify for this durable 
medical equipment. 
 
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 mattress. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you do not have multiple stage II pressure ulcers located on the trunk or pelvis which have failed to 
improve over the last month. You do not have large or multiple stage III or IV pressure ulcer(s) on the trunk or 
pelvis or a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days. 
 
 
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 mattress have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a powered pressure reducing air mattress.