Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPAP accessories (A7034, A7038, E0562) provided March 
12, 2020. 
 
You asked the Plan to pay for the CPAP accessories. You say that the items were medically necessary. The 
Plan denied your request. The Plan says items provided by non-Medicare providers are not covered. 
 
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 provider 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. This 
provider is an online supplier that does not participate in the Medicare program. Therefore, we decided that the 
Plan does not have to pay for CPAP accessories (A7034, A7038, E0562) provided March 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 50590 provided on September 25, 2019. 
 
You asked the Plan to pay for CPT code 50590. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. for Medicare to consider coverage and payment for any item or service, 
the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's 
medical documentation and confirm that Medicare coverage criteria have been met. 
 
We find that CPT code  is not supported in the medical record. Specifically, the medical records provided do 
not have the enrollee's name listed on them and we are unable to verify if the records corroborate the services 
billed. Based on this information, we decided that Medicare rules for coverage of CPT code 50590 have not 
been met. Therefore, we decided that the Plan does not have to pay for CPT code 50590 provided on 
September 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient behavioral health inpatient services provided 
from March 17, 2020 to March 24, 2020 by an out of network provider. 
 
You asked the Plan to pay for the inpatient behavioral health inpatient services. You say that the services were 
medically necessary so the claim should be paid. The Plan denied your request. The Plan says they will 
approve dates of service March 15, 2020 to March 16, 2020 but you did not request prior authorization for the 
remaining 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 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 the inpatient behavioral health inpatient services provided from March 17, 2020 
to March 24, 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 three anterior resin-based composites of two surfaces 
(D2331 x3) and posterior resin-based composite of one surface (D2391) provided on May 14, 2020. 
 
You asked the Plan to pay for the resin-based composites. You say that the policy was modified in January 
2020, and these services should be covered. The Plan denied your request. The Plan says these services are not 
covered benefits under your dental plan. The Plan also says that you were not enrolled in the dental plan rider 
on this date of service. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the three 
anterior resin-based composites of two surfaces (D2331 x3) and posterior resin-based composite of one surface 
(D2391) provided on May 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) rendered by the out of network 
(OON) provider on January 22, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service 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 this service. Therefore, we decided that the Plan does not 
have to pay for the office visit (99213) rendered by the out of network (OON) provider on January 22, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for destruction by neurolytic agent, paravertebral facet joint nerve(s), with 
imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (CPT Code 64636 x 2) 
provided on March 19, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the services are not supported by the records. 
 
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 physician reviewer found 
the provider correctly billed for greater than 2 levels with code 64636 x 2. The documentation supports that 3 
levels bilaterally were performed. 
 
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 
destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); 
lumbar or sacral, each additional facet joint (CPT Code 64636 x 2) provided on March 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay you had from 
April 4, 2020 through April 8, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you think this amount 
is excessive. The Plan denied your request. The Plan says you were charged this amount 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 $275 
copayment per day for days 1-5 for inpatient hospital services.  
 
You have been asked to pay a $275 copayment per day for days 1-5, for a total of $1100. 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 inpatient hospital stay you had from April 4, 2020 through April 
8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 3, 2020. 
 
You asked the Plan to pay for the physician's services. 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 
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 June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by an out-
of-network provider on February 25, 2020 to February 26, 2020. 
 
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you did not have the 
choice of what facility to go to. The Plan denied your request. The Plan says the correct coinsurance has been 
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 40% 
coinsurance for outpatient surgery/out-of-network.  
 
You have been asked to pay a 40% coinsurance of the allowed amount for an outpatient surgery. The total 
allowed amount is $6,097.12. The total amount you are being asked to pay is $2,438.85 ($6,097.12 x 40% = 
$2,438.85). Since these services were provided in a non-participating facility, the correct coinsurance has been 
applied. An outpatient surgery falls within the outpatient surgery/out-of-network 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 an outpatient surgery provided by an out-of-network provider on 
February 25, 2020 to February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on November 6, 2019. 
 
You asked the Plan to pay for the definitive drug testing. You say that these codes are supported and should be 
paid. The Plan denied your request. The Plan says the office visit and presumptive drug test was approved for 
payment. There is no documentation of the results of the definitive drug testing to justify payment for this. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage can only be considered when sufficient 
information is submitted to confirm that coverage criteria have been met.  
 
In this case, there is no evidence of the results of the definitive drug testing that was billed. Without these 
results, it cannot be confirmed that the service was provided or that the coverage criteria were met. Therefore, 
we decided that the Plan does not have to pay for the definitive drug testing provided on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (CPT 01992) provided to the enrollee on 
February 7, 2020. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says minor pain procedures, under most routine circumstances, do not require anesthesia care 
other than local anesthesia. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the patient has no significant previous medical history to warrant MAC.  There is no 
documentation in the enrollee's record indicating that it is medically necessary to have an anesthesiologist 
present during an LESI.  Medical necessity for an anesthesiologist to administer MAC/IV sedation was not 
established.  The review has determined that the anesthesia services performed were not necessary. The review 
determined that it was not medically necessary or reasonable for this enrollee to have IV sedation during the 
LESI performed. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia services (CPT 01992) provided to the enrollee on February 7, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for dermatology services received from January 30, 2020 to February 24, 
2020. 
 
You asked the Plan to pay for the services. You say that your PCP provided a referral for this treatment. The 
Plan denied your request. The Plan says that they have not yet received an itemized bill. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the services by a contract provider. Your PCP is a contract provider. The file does not 
show that the Plan provided notice that the services would not be covered. Under Medicare rules, this means 
the services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for dermatology 
services received from January 30, 2020 to February 24, 2020.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DME provided on January 27, 2020. 
 
You asked the Plan to pay for the DME. 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 
DME items. We found no exception that would require the Plan to pay for these items. Therefore, we decided 
that the Plan does not have to pay for DME provided on January 27, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on December 25, 2019. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you left around 5 in the 
morning. You say that you left without even receiving as much as an Aspirin. The Plan denied your request. 
The Plan says the correct copayment has been 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. Since an emergency room visit did 
occur, the correct copayment has been applied. An emergency room visit falls within the emergency 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 an emergency room visit 
provided by a participating provider on December 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient hospital care provided from  
May 16, 2020 to May 18, 2020 and May 22, 2020 to May 24, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments 
have been applied correctly to the services provided. 
 
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 each time you are admitted to an acute care hospital.  
 
You have been asked to pay $600 ($300 copayment x 2 admissions) for the inpatient hospital care provided. 
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 inpatient hospital care provided from May 16, 2020 to 
May 18, 2020 and May 22, 2020 to May 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 2, 2019 and 
September 24, 2019. 
 
You asked the Plan to pay for the physician's services. 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 
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 August 2, 2019 and 
September 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical supplies (A6021, A6196, A6252, A6402 and 
A6454) provided on January 9, 2020. 
 
You asked the Plan to pay for the medical supplies. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the medical supplies (A6021, A6196, A6252, A6402 and A6454) 
provided on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided from March 11, 
2020 to April 22, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
services rendered by non-participating 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 from March 11, 2020 
to April 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a behavioral health inpatient admission provided from March 
23, 2020 to  
April 1, 2020. 
 
You asked the Plan to pay for the behavioral health inpatient admission. The Plan denied your request. The 
Plan says prior authorization was not obtained by the provider or 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 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 behavioral health inpatient admission provided from March 23, 
2020 to April 1, 2020.