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

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 6, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 requested 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 subsequent nursing facility care provided on May 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an esophagogastroduodenoscopy (43235) 
provided on October 12, 2020 and diagnostic x-ray (74246) provided on October 19, 2020. 
 
You asked the Plan to waive the copayments for the surgical procedure and x-ray. You say that you did not 
have a payment responsibility for your colonoscopy, and therefore should not be expected to pay for the other 
services provided. The Plan denied your request. The Plan says outpatient surgery services require a $300 
copayment and x-rays require a $130 copayment when they are provided at any location other than your 
physician's office. 
 
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 $300 
copayment for outpatient surgery services and a $130 copayment for x-rays provided at outpatient hospital 
facilities.  
 
You have been asked to pay a $300 copayment for an esophagogastroduodenoscopy (a surgical procedure) and 
a $124.61 copayment for an x-ray provided at an outpatient hospital facility. These services fall within the 
outpatient hospital services 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 
esophagogastroduodenoscopy (43235) provided on October 12, 2020 and diagnostic x-ray (74246) provided on 
October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy and a second opinion with an out of 
network (OON) gastroenterologist. 
 
You asked the Plan to pre-approve the colonoscopy and the second opinion with an OON gastroenterologist.. 
You say that the colonoscopy is medically necessary. You say that you would like to see the requested out of 
network provider because it is a doctor who diagnoses and treats acute or chronic liver disease, ranging from 
fatty liver disease to cirrhosis to liver cancer. The Plan denied your request. The Plan says a repeat screening 
colonoscopy is not currently medically necessary. The Plan says that an out of network provider is not 
necessary, as there are in plan providers who can supply the care needed. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees? needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
 
 
 
 
 
 
 
 
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 colonoscopy and the second opinion 
with an OON gastroenterologist. Our reviewer says that the criteria for coverage of the requested services have 
not been met. Our physician reviewer found the enrollee has a history of viral hepatitis C, stage 3 liver fibrosis, 
fatty liver with normal transaminase level (ALT 34 on March 8, 2019). The appellant reports that a sub-
centimeter hypoechoic nonspecific lesion was identified in her left liver lobe by ultrasound in September of 
2020. A prior colonoscopy performed on November 21, 2019, identified pan-colonic diverticulosis and 
diminutive cecal tubular adenoma. The enrollee's last colonoscopy was performed uneventfully and to 
completion on October 6, 2020. The standard of care in follow-up to the enrollee's complete colonoscopy and 
history of diminutive single tubular adenoma warrants colonoscopy surveillance no sooner than at a 7-10-year 
interval per USTF guidelines. Our physician reviewer found that the records provided do not support the 
medical necessity for a colonoscopy at this time. Our physician reviewer also found that specialty care 
expertise exists in-network for follow-up physical examination, liver re-imaging, image and laboratory 
interpretation, and treatment options pertinent to the enrollee's ultrasound findings in the context of her stage 3 
liver fibrosis. 
 
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 colonoscopy and the second opinion with an OON gastroenterologist. have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a colonoscopy and a second 
opinion with an out of network (OON) gastroenterologist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for prolonged evaluation and management services (99358) 
provided on September 9, 2020. 
 
You asked the Plan to pay for prolonged evaluation and management services. You say that this is a payable 
code. The Plan denied your request. The Plan says this service was not billed correctly. 
 
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 99358 is prolonged evaluation and management service 
before and/or after direct patient care; first hour. 
 
We find that CPT code 99358 is not supported in the medical record. Specifically, the record does not show 
that this service was performed before or after direct patient care. Based on this information, we decided that 
Medicare rules for coverage of prolonged evaluation and management services have not been met. Therefore, 
we decided that the Plan does not have to pay for prolonged evaluation and management services (99358) 
provided on September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay at the in-network rate for proton beam radiation provided to the 
enrollee from March 2, 2020, through March 31, 2020, by an out-of-network provider. 
 
You asked the Plan to pay at the in-network rate the services. You say that you feel this should be paid at the 
in-network rate. The Plan denied your request. The Plan says the enrollee had access to care in-network and 
this was not an emergency. The Plan states they will pay in-network for out-of-network services when the care 
is an emergency and care is not available in-network. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided 
that Medicare rules for coverage of the services have not been met. You requested a prior authorization for 
proton beam treatments be covered as in-network for out-of-network services. The prior authorization was 
denied because the enrollee has access to care in-network and the services were not an emergency. According 
to the Plan's records, the prior authorization denial was issued on December 12, 2019, notifying you the 
services would not be covered in-network. The services were performed after the denial of prior authorization 
was issued. Therefore, the appeal is denied to cover in-network. Therefore, we decided that the Plan does not 
have to pay at the in-network rate for proton beam radiation provided to the enrollee from March 2, 2020, 
through March 31, 2020, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3 additional dental implants provided on September 15, 
2020. 
 
You asked the Plan to pay for the additional dental implants. You say that you would like this claim covered. 
The Plan denied your request. The Plan says the claim processed correctly. 
 
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. The Plan covers dental 
implants once every 5 years. 
 
We looked at the file and Medicare rules. The file indicates that the Plan approved one dental implant on 
September 15, 2020, but denied the 3 additional dental implants you received. In addition, because you 
received services from an OON provider, the claim processed correctly at 50% coinsurance and the provider is 
allowed to balance bill you the difference between the charged price and the Medicare-allowed amount. Based 
on this information, we decided that the Plan's rules for coverage of the additional dental implants have not 
been met. Therefore, we decided that the Plan does not have to pay for the 3 additional dental implants 
provided on September 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the exenteration of orbit services coded 65110 provided on 
August 12, 2019. 
 
You asked the Plan to pay for the exenteration of orbit 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 65110 is exenteration of orbit (does not include skin 
graft), removal of orbital contents; only. 
 
We find that CPT code 65110 is not supported in the medical record. Specifically, this code was billed with 
modifier 79. The documentation submitted indicates that the procedure was performed by two surgeons. There 
is a more appropriate modifier that should be appended for the services billed. Based on this information, we 
decided that Medicare rules for coverage of the exenteration of orbit services have not been met. Therefore, we 
decided that the Plan does not have to pay for the exenteration of orbit services coded 65110 provided on 
August 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional moderate sedation services provided on 
September 17, 2020. 
 
You asked the Plan to pay for the moderate sedation services. You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says the procedure code was billed with the wrong POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate POS code. 
 
In this case, code 99153 cannot be paid as billed due to an error with the POS code reported. Medicare billing 
criteria are not met. Therefore, the Plan does not have to pay for services provided under code 99153 on 
September 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July 
5, 2020, through July 9, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that it is evident that you 
should have never been discharged the first time. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows that you were seen in the emergency room on July 5, 2020, and then admitted for 
inpatient hospital care on July 6, 2020, and discharged on July 9, 2020. You were asked to pay a $285 
copayment per day from July 6, 2020, through July 8, 2020, days 1-3 of your inpatient hospital care. You were 
discharged on July 9, 2020, and there was no copayment charge for the day of discharge. Per your contract 
there is a $285 copayment per day required for days 1-6. 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 inpatient hospital care provided from July 5, 2020, through July 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 18, 
2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 requested 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 subsequent nursing facility care provided on February 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and the 
bitewing x-rays (D0272) provided on January 8, 2020. 
 
You asked the Plan to pay for the dental services. You say that the enrollee was advised that nothing changed 
when the carrier changed names. The Plan denied your request. The Plan says you are not an in network 
provider with the enrollee's plan. The Plan also says that services that are rendered out of network 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, dental services that are provided by an 
out of network provider are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for the oral exam (D0120), prophylaxis (D1110), and the bitewing x-rays (D0272) 
provided on January 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services (88305) provided July 28, 
2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that the copayment should be waived. 
The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 
copayment for lab testing.  
 
You have been asked to pay a $20 copayment for the lab services. The lab services falls within the lab testing 
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 lab services (88305) provided 
July 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for lab services (80061, 36415, 80053) 
provided January 10, 2020. 
 
You asked the Plan to waive the deductible for the lab services. You say that you have never been charged for 
this service before. The Plan denied your request. The Plan says the deductible was correctly applied. 
 
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 there is a $250 deductible for lab services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category lab services. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible for 
lab services. This cost sharing is a contractual obligation that had not been met at the time the lab services was 
received on January 10, 2020. Therefore, we decided that the Plan does not have to waive the deductible for lab 
services (80061, 36415, 80053) provided January 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88342, 88305) provided on December 12, 2019 
to December 19, 2019. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there were network providers available. 
 
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 had network providers 
available who could have provided the services 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 these services. Therefore, we decided 
that the Plan does not have to pay for lab services (88342, 88305) provided on December 12, 2019 to 
December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a pain management visit (99205) provided 
May 21, 2019. 
 
You asked the Plan to waive the copayment for the pain management visit. You say that the copayment should 
be waived. The Plan denied your request. The Plan says the correct amount was applied. 
 
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 have been asked to pay a $35 copayment for the pain management visit. The pain management visit falls 
within the specialist 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 pain 
management visit (99205) provided May 21, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an aneurysm screening (76706) provided October 14, 
2020. 
 
You asked the Plan to pre-approve the aneurysm screening. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the benefit for this service was exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that an Abdominal Aortic Aneurysm Screening is 
only covered for beneficiaries that have not been previously furnished with this test. 
 
We looked at the file and Medicare rules. This test is only covered on a one-time basis. This test was 
previously provided on June 3, 2020. Based on this information, we decided that Medicare rules for coverage 
of the aneurysm screening have not been met. Therefore, we decided that the Plan does not have to pre-approve 
an aneurysm screening (76706) provided October 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a Freestyle Libre Sensor Continuous Glucose monitor 
(CGM). 
 
You asked the Plan to preapprove the CGM. You say that you have been using a CGM and you feel it helps 
your blood sugar levels. The Plan denied your request. The Plan says you do not meet Medicare coverage 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan 
does not have to preapprove a Freestyle Libre Sensor Continuous Glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 3, 2020. 
 
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 procedure codes 87500 and 87801 are not supported. 
 
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 87500 is infectious agent detection by nucleic acid (DNA 
or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique. The 
definition of code 87801 is infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; 
amplified probe(s) technique. 
 
We find that CPT codes 87500 and 87801 are not supported in the medical record. Specifically, there is no 
documentation of infectious agent detection for vancomycin resistance to support code 87500. There is no 
documentation of infectious agent detection of multiple organisms to support code 87801. 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 laboratory services rendered on June 3, 2020.