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

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on January 17, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network 
deficiency for 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 services at issue in this appeal. 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 medical services provided to the enrollee by an out-of-network provider 
on January 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to make additional payment for the mandibular partial denture and two 
extractions provided on March 11, 2020. 
 
You asked the Plan to make additional payment for the mandibular partial denture and extractions. You say 
that you took out a loan to pay for these services. You also say that you do not understand why so much was 
billed for these services. The Plan denied your request. The Plan says this claim processed correctly according 
to your 2020 EOC. 
 
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, you are responsible for a 70% 
coinsurance for partial dentures. The contract also clearly states that you are responsible for a 50% coinsurance 
for each extraction. Therefore, we decided that the Plan does not have to make additional payment for the 
mandibular partial denture and two extractions provided on March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids purchased out of network on January 30, 2020. 
 
You asked the Plan to pay for out of network hearing aids. You say that these hearing aids should be covered. 
The Plan denied your request. The Plan says the hearing aids were not purchased from a Plan provider. 
 
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 
hearing aids only when purchased by designated providers. The hearing aids in this appeal were purchased out 
of network. Therefore, we decided that the Plan does not have to pay for hearing aids purchased out of network 
on January 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance (eg, proton) imaging (MRI), spinal canal and contents, lumbar; with contrast material(s) (72149), for the enrollee.
You asked the Plan to pre-approve the MRI. You say that the enrollee had surgery to treat a problem with their spine. The Plan denied your request. The Plan says the records do not show that the enrollee had follow up contact with the enrollee's doctor to look at the enrollee's progress after a six-week trial of doctor prescribed treatment.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI. Our physician reviewer found the patient has not been formally examined and has not been a part of any type of treatment or rehab or program to assess progress or lack thereof to substantiate the need for an MRI of the spine. The enrollee has known pathology in their spine. Our doctor would like to see pain more formally assessed and some plan of physical therapy or otherwise over a longer time period before getting MRI. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance (eg, proton) imaging (MRI), spinal canal and contents, lumbar; with contrast material(s) (72149), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 27, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 pay for the drug testing rendered on August 27, 2019.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing services (HCPCS G0482) provided to the enrollee on 
October 23, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the medical records submitted do not include a completed physician order or intent to order 
for the billed test. 
 
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 G0482 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed." 
 
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 pay for the services. Our reviewer says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found the 
laboratory submitted a valid/signed physician laboratory requisition form and lab results. The review has 
determined that the records support the denied codes. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
drug testing services (HCPCS G0482) provided to the enrollee on October 23, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on January 28, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network 
deficiency for 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 services at issue in this appeal. 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 medical services provided to the enrollee by an out-of-network provider 
on January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) (E0471) provided on January 28, 2020.
You asked the Plan to pay for the DME. You say that you have sleep apnea and you need the equipment. The Plan denied your request. The Plan says the DME is not medically necessary.
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 pay for the DME. Our physician reviewer found criteria for continued coverage of BiPAP are not met. This patient has not had a follow-up clinical visit after starting on BiPAP to confirm benefit, and compliance report does not meet the minimum requirements of at least 4 hrs/night for at least 70% of nights. Usage is insufficient to be of benefit, and therefore BiPAP is considered not medically necessary. 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 DME have not been met. Therefore, we decided that the Plan does not have to pay for respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) (E0471) provided on January 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 2, 2020 through February 4, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found based on the documentation provided, this hospitalization does not qualify for inpatient payment under the two-midnight rule. At the time of admission, it was not reasonable to expect that two midnights in the hospital would be required. The enrollee, a known diabetic, was found to have hypoglycemia after taking insulin, but not eating. The enrollee responded to standard therapy. No additional life/limb threatening conditions were identified. Then the enrollee could have been safely monitored on observation status before deciding if two midnights of in-hospital care would be medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 2, 2020 through February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitoring system for the 
enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records provided indicate that the enrollee only checks his blood sugar up to three 
times per day. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
Despite multiple attempts, there was no records received. It cannot be determined if the criteria has been met 
for this monitor. Based on this information, we decided that Medicare rules for coverage of the monitor have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose 
monitoring system for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bupropion HCl. 
 
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 self-administered drugs are not covered. 
 
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 pre-approve Bupropion HCl.  
 
Benefits for these services 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 waive the copayment for a telemedicine pulmonology office visit 
provided on May 12, 2020. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you are upset that you have to pay 
this copayment for a telemedicine visit. 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 $40 
copayment for specialist visit.  
 
You have been asked to pay $40 copayment for specialist visit. specialist visit 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 copayment for a telemedicine pulmonology office visit provided on May 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of a thigh fracture (27244) provided on 
February 20, 2020. 
 
You asked the Plan to pay for the treatment of a thigh fracture. You say that this code allows for cables instead 
of a plate or screws. The Plan denied your request. The Plan says this code is not appropriate for the service 
performed. 
 
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 27244 is treatment of intertrochanteric, peritrochanteric, 
or subtrochanteric femoral fracture; with plate/screw type implant, with or without cerclage. 
 
We find that CPT code 27244 is not supported in the medical record. Specifically, this code requires a 
plate/screw type implant. The submitted medical records do not indicate a plate/screw type implant was placed. 
Based on this information, we decided that Medicare rules for coverage of the treatment of a thigh fracture 
have not been met. Therefore, we decided that the Plan does not have to pay for the treatment of a thigh 
fracture (27244) provided on February 20, 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 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 was medically stable with debility with no evidence of need for
supervision by a physical, medicine, and rehabilitation (PMR) Physician or needs acute rehab nursing care. The
enrollee may benefit from further physical therapy (PT) and occupational therapy (OT) but does not require an
intensive therapy program. IRF admission is not medically necessary based on the enrollee's current
participation and lack of medical complexity.
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services coded as A0120, A0180 and A0190 
provided while traveling outside of the U.S. on March 23, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you have turned in the documents for the 
claim and have paid this out of pocket. You were told over the phone this would be covered. The Plan denied 
your request. The Plan says the requested proof of payment has not been received. Without proof of payment, 
the plan is unable to reimburse the enrollee 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care. The health plan contract also says if you have an urgent need for care while outside of the 
U.S. and its territories, you will be responsible to pay for the services rendered upfront. You must submit proof 
of payment for reimbursement. The plan has made multiple attempts to obtain proof of payment.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for the ambulance services coded as A0120, A0180 and A0190 provided while traveling outside of the 
U.S. on March 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the pneumatic compression device (PCD) 
provided on March 13, 2020. 
 
You asked the Plan to waive the coinsurance for the PCD. You say that you should not have to pay for this. 
The Plan denied your request. The Plan says that 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 a 25% 
coinsurance for out-of-network durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a 25% coinsurance for the PCD. The PCD falls within the out-of-network durable 
medical equipment (DME) and related 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 
coinsurance for the pneumatic compression device (PCD) provided on March 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 2, 2020. 
 
You asked the Plan to pay for the laboratory testing. 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 and the ordering physician are not network providers with the Plan. The 
Plan did not pre-approve the laboratory testing. 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 testing provided on 
January 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown (D2751) and prefabricated post and core (D2954) for tooth #'s 9 and 10.
You asked the Plan to pre-approve the crown (D2751) and prefabricated post and core (D2954) for tooth #'s 9 and 10. The Plan denied your request. The Plan says the service is limited to once every 5 years.
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 also has a maximum benefit of one crown per tooth every 5 years. The Plan paid for a crown for tooth #'s 9 and 10 provided on January 7, 2019, which exhausted the benefit. Therefore, we decided that the Plan does not have to pre-approve the crown (D2751) and prefabricated post and core (D2954) for tooth #'s 9 and 10.