Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services rendered on July 28, 
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 the provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that a licensed professional counselor is not eligible to 
participate in Medicare.  
 
We looked at the file and Medicare rules. The file shows that you received services from a licensed 
professional counselor. This provider type is not covered by Medicare. Therefore, we decided that the Plan 
does not have to pay for the outpatient mental health services rendered on July 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foam rubber mattress and pump with oxygenator 
rendered on May 27, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the foam rubber mattress and pump with oxygenator rendered on 
May 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) scan of the lower 
extremity joint (73721) rendered by the out of network (OON) provider. 
 
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 magnetic resonance imaging (MRI) scan of the lower extremity joint (73721) rendered by 
the out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for diagnostic radiology provided from March 
12, 2020, to June 30, 2020. 
 
You asked the Plan to waive the copayments for diagnostic radiology. You say that you did not know that the 
provider was out-of-network and you are being charged in addition to the $50 copayment. The Plan denied 
your request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
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 $100 
copayment for each diagnostic radiology service. 
 
You received diagnostic radiology from March 12, 2020, to June 30, 2020. Therefore, you are responsible to 
pay your share of the cost-sharing charges. Please see the chart below.  
 
 
Date of Service  Service Codes Allowed Amount Amount You Owe 
3/12/2020 93970 $202.27 $100 
5/28/2020 93971 $125.98 $100 
6/4/2020 93971 $125.98 $100 
6/11/2020 93971 $125.98 $100 
6/11/2020 76942 $59.86 $59.86 
6/18/2020 93971 $125.98 $100 
6/18/2020 76942 $59.86 $59.86 
 
 
6/30/2020 93971 $125.98 $100 
6/30/2020 76942 $59.86 $59.86 
 
The total amount you owe is: $779.58. 
 
You have been asked to pay a $100 copayment for diagnostic radiology. Diagnostic radiology falls within the 
outpatient diagnostic test and therapeutic services and 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 copayments for diagnostic radiology provided from March 12, 2020, to June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for medical supplies provided from January 2, 
2020, to May 14, 2020. 
 
You asked the Plan to waive the coinsurance for medical supplies. You say that you thought that you would 
only owe a $30 copayment. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct amount. 
 
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 20% 
coinsurance for medical supplies. 
 
You received medical supplies provided from January 2, 2020, to May 14, 2020. Therefore, you are responsible 
to pay your share of the cost-sharing charges. Please see the chart below.  
 
Date of Service  Billing Code Allowed Amount Amount You Owe 
1/2/2020 Q4186 $2,940.53 $7.77 
1/9/2020 Q4186 $2,940.30 $588.06 
4/16/2020 Q4186 $2,908.26 $581.65 
4/23/2020 Q4186 $2,908.26 $581.65 
5/7/2020 Q4186 $2,908.26 $581.65 
5/14/2020 Q4186 $2,908.26 $581.65 
 
The total amount you owe is: $2,922.43.  
 
 
You have been asked to pay the total coinsurance amount of $2,922.43 for medical supplies. Medical supplies 
fall within the outpatient diagnostic tests and therapeutic services and 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 medical supplies provided from January 2, 2020, to May 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete maxillary dentures. 
 
You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your 
request. The Plan says the benefit has been exhausted. 
 
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 dentures one 
time every sixty months.  
 
Dentures were last received less than five years ago on April 18, 2018. Based on this information, we decided 
that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does 
not have to pre-approve complete maxillary dentures.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve CPAP supplies. 
 
You asked the Plan to pre-approve the supplies. You say that you would like reconsideration because new 
supplies will decrease the member's discomfort and increase the member's compliance to treatment. The Plan 
denied your request. The Plan says that there is no clinical information showing the member has been 
compliant with current CPAP usage. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 supplies. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the member has severe Obstructive Sleep Apnea and significant cardiac disease and is 
experiencing discomfort with her current mask. The member would benefit from continued treatment of the 
OSA. It is reasonable to provide the new supplies and to give the member another opportunity to achieve 
compliance. 
 
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 supplies have been met. Therefore, we decided that the Plan has to pre-
approve CPAP supplies.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram interpretation and report provided on 
July 16, 2020. 
 
You asked the Plan to pay for the electrocardiogram, routine ECG with at least 12 leads; interpretation and 
report only (93010). You say that the Plan should pay this claim. The Plan denied your request. The Plan says 
there is no documentation of an interpretation from the provider. 
 
 
 
The Plan must follow Medicare rules. Medicare does not allow physicians of the same group to bill the same 
enrollee for the same type of service on the same day.  
 
Based on Medicare billing guidelines, this claim cannot be paid as billed therefore, we decided that Medicare 
rules for coverage of the ECG services have not been met. Therefore, we decided that the Plan does not have to 
pay for the electrocardiogram interpretation and report provided on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291 and 99292) provided on 
November 21, 2020, through November 27, 2020. 
 
You asked the Plan to pay for the critical care services. You say that you would like reconsideration because 
the services rendered were medically appropriate. The Plan denied your request. The Plan says the 
documentation does not support the service billed. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
The CPT Code Manual definition of code 99292 is critical care, evaluation and management of the critically ill 
or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service). 
 
We find that CPT codes 99291 and 99292 are not supported in the record. Specifically, the documentation 
submitted does not include a progress note indicating the total time spent providing the critical care services. 
Based on this information, we decided that Medicare rules for coverage of the critical care services have not 
been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291 and 99292) 
provided on November 21, 2020, through November 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that the Plan approved your partials, but you never received them. The Plan denied your request. The Plan 
says these services exceed the maximum count allowed per period. 
 
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, comprehensive oral evaluation 
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan 
years. The record shows that you received a comprehensive oral evaluation (D0150) and a complete series of 
intraoral x-rays (D0210), and your comprehensive oral evaluation (D0150) and 
complete series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan 
does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays 
(D0210) provided.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services provided on April 7, 2020. 
 
You asked the Plan to pay for moderate sedation services. You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says the billed service cannot be verified. 
 
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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older.  
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted 
did not indicate the presence of an independent trained observer to assist in the monitoring of the enrollee's 
level of consciousness and physiological status. Based on this information, we decided that Medicare rules for 
coverage of moderate sedation services have not been met. Therefore, we decided that the Plan does not have 
to pay for moderate sedation services provided on April 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted evaluation and management service (special pads to 
put in shoes (called foot inserts) (CPT Code 99499 x 2). 
 
You asked the Plan to pay for the services. You say that you are requesting review of denial of services. The 
Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. The 
services are not covered. Therefore, we decided that the Plan does not have to pay for unlisted evaluation and 
management service (special pads to put in shoes (called foot inserts) (CPT Code 99499 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you have balance issues and fear of falling in 
the shower. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture, maxillary (D5110). 
 
You asked the Plan to pre-approve complete denture. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not a covered benefit. 
 
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. If the service is not listed on 
the Plan?s EOC then they are not covered. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve complete 
denture, maxillary (D5110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medicallynecessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 topre-approve the LTACH services. Our reviewer says that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on November 20, 2020,with a left groin abscess, septic shock, and respiratory failure. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.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 LTACH services have not been met.Therefore, we decided that the Plan does not have topre-approvelong-term acute care hospital (LTACH) services
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network ophthalmologist. 
 
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 the services are available from network providers. 
 
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 
a referral to an out-of-network ophthalmologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on July 16, 2020. 
 
You asked the Plan to pay for the bitewing x-rays. You say that the provider in this case is in network with the 
Dental Plan. You say that the provider is listed in the Provider Directory. You also say that the services should 
be covered. The Plan denied your request. The Plan says bitewing x-rays are not listed as a covered 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 bitewing x-rays are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bitewing x-
rays (D0274) provided on July 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided. 
 
You asked the Plan to pay for the paramedic intercept services. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area.  
 
The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we 
decided that the Plan does not have to pay for the paramedic intercept services provided.