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

 
We decided that the Plan does not have to pay for physician's services provided on July 6, 2020. 
 
You asked the Plan to pay for the physician's 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 
physicians 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 July 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan (74176) provided on June 
27, 2020. 
 
You asked the Plan to pay for a CT scan. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not billed with the correct primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that the ICD-10-CM has a coding convention that 
requires the underlying condition be sequenced first, if applicable, followed by the manifestation.  Wherever 
such a combination exists, there is a use additional code note at the etiology code, and a code first note at 
the manifestation code. 
 
We looked at the file and Medicare rules. The billed primary diagnosis, R65.21, is a manifestation code with a 
code first note. It should be sequenced after the etiology code. Based on this information, we decided that 
Medicare rules for coverage of a CT scan have not been met. Therefore, we decided that the Plan does not have 
to pay for a computed tomography (CT) scan (74176) provided on June 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthroplasty services coded 23472 provided on April 22, 
2020. 
 
You asked the Plan to pay for the arthroplasty 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 23472 is arthroplasty, glenohumeral joint; total shoulder 
(glenoid and proximal humeral replacement (eg, total shoulder)). 
 
We find that CPT code 23472 is not supported in the medical record. Specifically, the operative report did not 
include documentation of a total shoulder arthroplasty; therefore, this code cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of the arthroplasty services have not been met. 
Therefore, we decided that the Plan does not have to pay for the arthroplasty services coded 23472 provided on 
April 22, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from May 30, 2020, to 
June 9, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled 
Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from January 17, 
2020, to July 19, 2020. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing services provided from May 30, 2020, to June 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter (E1399). 
 
You asked the Plan to pre-approve the power scooter. You say that you need the scooter to get to medical 
appointments and are homebound without it. The Plan denied your request. The Plan says equipment for use 
outside the home is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The record indicates the item at issue in this appeal is for use outside of the home. Although this item may be 
helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that 
the Plan does not have to pre-approve a power scooter (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 7, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on August 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nafcillin 2 GM/100 ML injection (CPT Code J3490). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
Based on the documentation in the file, we have confirmed that this drug will be provided in a nursing facility 
during a stay not covered by Medicare Part A. This drug will be provided by nursing home staff and will not 
represent an expense to a physician or be included in a physician's bill. As such, it is not eligible for Part B 
coverage. Therefore, we decided that the Plan does not have to pre-approve Nafcillin 2 GM/100 ML injection 
(CPT Code J3490).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis and sleeve provided to the enrollee on May 
12, 2020. 
 
You asked the Plan to pay for these services. You say that these items were medically necessary. The Plan 
denied your request. The Plan says that the enrollee did not visit with the referring provider. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
 
 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthosis and sleeve 
provided to the enrollee on May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visits (99214, 99215) and debridement 
down to and including subcutaneous tissue (11042) provided on May 27, 2020 to June 3, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the office visits. You say that no one who presents to the clinic is turned away 
regardless of insurance. As the care was given in good faith you ask for reimbursement. The Plan denied your 
request. The Plan says enrollee's must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 outpatient office visits (99214, 99215) and 
debridement down to and including subcutaneous tissue (11042) provided on May 27, 2020 to June 3, 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 sinus augmentation with bone provided on March 12, 
2020. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the amount for the sinus 
augmentation with bone. You also say that you should have only had to pay a copayment for the service. The 
Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says 
that payment cannot be made for services that you receive from a provider who has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the sinus 
augmentation with bone provided on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on April 13, 2020. 
 
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, 
nor were they 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 did not pre-approve the 
drug test. 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 a drug test provided on April 13, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the SNF care provided from July 10, 2020, 
to August 10, 2020. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you are being billed because you 
were at the facility for more than 21 days. 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 a $0 
copayment per day for days 1 to 20 and a $165 copayment per day for days 21 to 100 for Skilled nursing 
facility (SNF) care. This SNF stay lasted 31 days, resulting in a copayment amount of $1,485. 
 
You have been asked to pay a $0 copayment per day for days 1 to 20 and a $165 copayment per day for days 
21 to 100 for the SNF care. The 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 SNF care provided from July 10, 2020, to August 10, 
2020.