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

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the services are 
necessary. The Plan denied your request. The Plan says you exhausted your benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. The 21st trip and 
beyond is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve additional 
routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on April 6, 
2020 by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the services were medically 
necessary and provided in good faith. The Plan denied your request. The Plan says the service was rendered by 
a non-network provider who does not work with the enrollee's health plan. The Plan also says that the enrollee 
was referred by his non-participating outpatient nursing facility. 
 
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 subsequent nursing facility care provided on 
April 6, 2020 by an OON provider.
Appeal type: Testing
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 August 11, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
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 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 August 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 8, 2020. 
 
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 pre-authorization was not obtained before services were 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 laboratory services provided to the enrollee on 
June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 16, 2020, by an out-of-
network provider. 
 
You asked the Plan to pay for the office visit. You say that the visit should be covered under a visitor and 
domestic travel plan. The Plan denied your request. The Plan says they do not offer a visitor and domestic 
travel plan option and the office visit was non-emergent. 
 
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.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the 
office visit provided on June 16, 2020, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-rays performed from May 7, 2020, 
through June 18, 2020, by an in-network provider. 
 
You asked the Plan to waive the copayment for the x-rays. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claims were 
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 show that you received x-rays on May 7, 2020 performed by an in-network provider. The 
provider billed the following procedure codes on the claim: 99203 (office or other outpatient visit for the 
evaluation and management of a new patient), 73564 (radiologic examination, knee; complete, 4 or more 
reviews) and 73502 (radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views). The 
provider billed procedure code 73564 in the amount of $173.00. The allowed amount for procedure code 73564 
is $30.04. The plan applied a $14.00 copayment to procedure code 73564. The provider billed procedure code 
73502 in the amount of $164.00. The allowed amount for procedure code 73502 is $31.01. The plan applied a 
$14.00 copayment to procedure code 73502. You received services on June 18, 2020. The provider billed the 
following procedure codes on the claim: 73610 RT (radiologic examination, ankle; complete, minimum of 3 
views, right side), 73610 LT (radiologic examination, ankle; complete, minimum of 3 views, left side) and 
99213 (office or other outpatient visit for the evaluation and management of an established patient). The 
provider billed procedure code 73610 twice on the claim for date of service June 18, 2020, once for the right 
side and then for the left side. Each charge for procedure code 73610 was billed in the amount of $138.00. The 
allowed amount for procedure code 73610 is $23.93. The plan applied a $14.00 copayment to each charge for 
procedure code 73610. Your EOC states that enrollees must pay a $14 copayment for each in-network 
 
 
Medicare-covered standard x-ray. 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 x-rays performed 
from May 7, 2020, through June 18, 2020, by an in-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on June 15, 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 code 71046 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 71046 and 32557. Code 71046 is a column II code with a 
modifier indicator of 1 when billed with column I code 32557. Code 71046 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest 
x-ray rendered on June 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical/thoracic facet joint block for the enrollee. 
 
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The 
Plan says there are no professional standards of care purporting improved health outcomes for facet joint injections for 
axial pain when the basis of the pain being considered for treatment has not been established. 
 
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 block. Our reviewer says that the requested services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the requirement is dual 
diagnostic blocks that show greater than 80% pain with each block set. Here, only the first set of blocks met this criteria. 
The block should be considered negative and another pain generator sought. Therefore, the request is considered not 
medically reasonable or 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 block have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
cervical/thoracic facet joint block for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve the CT scan, abdomen and pelvis; without contrast material (CPT 
Code 74176). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is necessary. The Plan denied your 
request. The Plan says that the CT scan is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our physician reviewer 
found based on ultrasound findings and recommendations the CT is indicated and reasonable. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve the CT scan, abdomen and pelvis; without contrast material (CPT Code 74176).  
 
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 MTHFR genetic testing (81291) and an unlisted molecular 
pathology procedure (81479) provided on May 21, 2020. 
 
You asked the Plan to pay for MTHFR genetic testing and an unlisted molecular pathology procedure. You say 
that these tests were medically necessary. The Plan denied your request. The Plan says these tests were 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. The rules also say there is broad consensus in 
the medical literature that MTHFR genotyping has no clinical utility in any clinical scenario. This testing is 
considered investigational and is not a Medicare benefit. 
 
The MTHFR genetic testing at issue is not a covered benefit. We also find that CPT code 81479 is not 
supported in the medical record. Specifically, the submitted medical records do not clearly indicate what this 
unlisted code has been used to report. Based on this information, we decided that Medicare rules for coverage 
of MTHFR genetic testing and an unlisted molecular pathology procedure have not been met.  
 
 
 
 
 
 
 
 
 
Therefore, we decided that the Plan does not have to pay for MTHFR genetic testing (81291) and an unlisted 
molecular pathology procedure (81479) provided on May 21, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient ultrasound on June 18, 2020. 
 
You asked the Plan to waive the copayment for the outpatient ultrasound. You say that you had the procedure 
asked if it was all paid and the hospital said nothing was due. 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 show that you received an outpatient ultrasound on June 18, 2020. You are asked to pay a 
$10 copayment for the ultrasound. Your EOC states that enrollees must pay a $10 copay for all other Medicare-
covered diagnostic procedures and tests. 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 
outpatient ultrasound on June 18, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac device monitoring and in home visit provided on 
January 20, 2020 by an out of network provider. 
 
You asked the Plan to pay for the cardiac device monitoring or in home visit. You say that the Plan should pay 
this claim. The Plan denied your request. The Plan says you did not request prior authorization for the out of 
network 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 cardiac device monitoring and in home visit provided on January 20, 2020 
by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on July 23, 2020. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 
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 a domiciliary or rest home visit provided on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you would like to have this claim approved. 
The Plan denied your request. The Plan says there are in-network providers available for these service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
specialist services to be provided 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 comprehensive oral evaluation (D0150) and the complete 
series of x-rays (D0210) provided. 
 
You asked the Plan to pay for the dental services. You say that before your cleaning, you had to get an oral 
exam and x-rays. You say that you thought these services would be covered. You say that you did not get the 
cleaning done. You also say that you do not want a bill for these services and they should be covered. The Plan 
denied your request. The Plan says comprehensive oral evaluations and complete series of x-rays are each 
covered once every 3 plan years. The Plan also says that the frequency limit for these services has been 
exceeded. 
 
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 and the services are listed as covered, 
the frequency limit of once every 3 plan years has been exceeded. The record shows that the Plan paid for these 
services that you received, thus exhausting your benefit. Therefore, we decided that the 
Plan does not have to pay for the comprehensive oral evaluation (D0150) and the complete series of x-rays 
(D0210) provided.
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 
that 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 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from September 17, 2018, to 
October 15, 2019. 
 
You asked the Plan to pay for the dental services. You say that your filing date was within the 1 year date from 
the completion of your implant. You also say that the implant was deemed medically necessary. The Plan 
denied your request. The Plan says these services are not covered by Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental services provided from 
September 17, 2018, to October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 28, 2019, by an 
OON provider. 
 
You asked the Plan to pay for a provider visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says rules for payment have not been met. 
 
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 28, 2019, 
by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lyrica for the enrollee. 
 
You asked the Plan to pre-approve Lyrica. You say that the enrollee is stable on this medication. The Plan 
denied your request. The Plan says that this is 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 pre-approve Lyrica for the enrollee.  
 
Benefits for Lyrica may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.