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

 
We decided that the Plan does not have to pay for the medical services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says prior 
authorization was not obtained as required. 
 
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 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 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the initial 15 minutes of conscious sedation (D9239), an 
additional 15 minutes of conscious sedation (D9243 ), and the unspecified oral surgery procedure.  
 
You asked the Plan to pre-approve the dental services. You say that the dental services are medically necessary. 
The Plan denied your request. The Plan says conscious sedation is not listed as covered. The Plan says that the 
unspecified oral surgery procedure is not listed as a covered service either. 
 
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. The Customer Handbook clearly states that if a dental item or service 
is not listed in the benefit chart or listed with NC, then it is not covered. Therefore, we decided that the Plan 
does not have to pre-approve the initial 15 minutes of conscious sedation (D9239), an additional 15 minutes of 
conscious sedation (D9243 ), and the unspecified oral surgery procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF care is medically necessary and that a skilled 
nursing facility level of care will not provide the daily physical therapy needed. The Plan denied your request. 
The Plan says the criteria for coverage of IRF care have not been met. The Plan says that the enrollee's care can 
be provided at a lower level. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for respiratory failure and COVID 19 pneumonia. The enrollee is medical conditions are stable. 
There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a 
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 4, 2019, by out-
of-network providers. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the providers are not in-network with the member's Plan. The Plan states the 
member's primary care physician did not refer for services and the services were not urgent or emergent. 
 
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 providers in this case are not network providers 
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 December 4, 2019, by out-of-network providers.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thoracic lumbar sacral orthosis (L0457) provided on July 
16, 2020. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not covered as the enrollee's evaluation 
did not take place at a qualifying originating site for a telehealth service. 
 
The Plan follows Medicare rules. Medicare rules say that if a spinal orthosis is provided and the coverage 
criteria are not met, the item will be denied as not medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for this item. Our reviewer says that this item is 
not medically necessary. Our physician reviewer found that the supporting documentation does not match the 
information sent on the claim. The patient has attempted other therapies previous to this date of service that 
were proven ineffective. The patient cannot ambulate without pain and discomfort. The record sent by the 
enrollee's provider indicates that he received a phone call from a DME (durable medical equipment) company 
vendor soliciting him to get the brace. The review has determined that the requested spinal orthosis in this case 
was 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 this item have not been met. Therefore, we decided that the Plan does not have 
to pay for the thoracic lumbar sacral orthosis (L0457) provided on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office or other outpatient visit for the evaluation and 
management of an established patient (CPT Code 99213 25) provided on September 9, 2020. 
 
You asked the Plan to pay for the services. You say that there are no bundling issues and the claim should be 
reprocessed for payment. The Plan denied your request. The Plan says this is part of the global surgical 
package. 
 
The Plan must follow Medicare rules. The rules say that The Medicare Fee Schedule Data Base (MFSDB) 
provides the postoperative periods that apply to each surgical procedure. If there is an indicator of 000, 
postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery.  
 
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. CPT code 99213-25 denied due to being considered as being a part 
of the global surgical package of major procedure code 69633 (Tympanoplasty without mastoidectomy 
(including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular chain 
reconstruction and synthetic prosthesis (eg, partial ossicular replacement prosthesis [PORP], total ossicular 
replacement prosthesis [TORP]) billed on July 27, 2020, by the same provider. Per the Medicare Claims 
Processing Manual, Chapter 12, section 40.1 A, the Global Surgical Package includes follow-up evaluation and 
management visits during the postoperative period of the surgery that are related to recovery from the surgery. 
Per review of the submitted documentation, CPT code 99213, is not supported as being performed on date of 
service September 9, 2020. Therefore, we decided that the Plan does not have to pay for office or other 
outpatient visit for the evaluation and management of an established patient (CPT Code 99213 25) provided on 
September 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on February 19, 2020. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the charges because you 
thought you would owe 0% coinsurance. 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 DME and related supplies.  
 
You received DME on February 19, 2020. The total allowed amount is $3,091.40 and 20% of that is $618.28.  
 
You have been asked to pay the total coinsurance amount of $618.28 for DME. DME falls within the DME and 
related supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for DME provided on 
February 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fixed dental bridge (D6740, D6245) provided May 13, 
2020. 
 
You asked the Plan to pay for the fixed bridge. You say that the fixed bridge is medically necessary. The Plan 
denied your request. The Plan says criteria for coverage has not been met. 
 
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 the fixed 
bridge when the services are medically necessary and reasonable.  
 
We looked at the plan contract, the file, and Medicare rules. There is no documentation that there is a 
documented physical or neurological disorder that would preclude placement of a removable prosthesis. Based 
on this information, we decided that the Plan's rules for coverage of the fixed bridge have not been met. 
Therefore, we decided that the Plan does not have to pay for a fixed dental bridge (D6740, D6245) provided 
May 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (77061) provided on 
August 25, 2020. 
 
You asked the Plan to pay for the diagnostic digital breast tomosynthesis. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 77061 
has a status indicator of I which is not valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 77061 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 77061 has a status indicator of I. This means that CPT code 77061 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the diagnostic digital breast 
tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic 
digital breast tomosynthesis (77061) provided on August 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgical procedure provided 
on July 8, 2020. 
 
You asked the Plan to waive the copayment for the outpatient surgical procedure. You say that you feel you 
should not be responsible for this cost share amount and you would like the Plan to reconsider your request. 
The Plan denied your request. The Plan says you received outpatient surgery provided in an Outpatient 
Hospital setting on the date of service at issue in this appeal. The Plan says that the correct copayment has 
applied per your contract with the Plan. 
 
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 each Medicare-covered outpatient surgery service.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an outpatient 
surgical service provided in an Outpatient Hospital setting on July 8, 2020. You have been asked to pay a 
$208.41 copayment for the outpatient surgical procedure, which is less than the contracted $300 copayment 
amount. The outpatient surgical procedure falls within the Outpatient surgery 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 the outpatient surgical procedure provided on July 8, 2020.  
 
Your complaint about the Plan applying the incorrect cost share because you paid for a specialist copayment on 
a prior visit is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental core buildup on tooth #30. 
 
You asked the Plan to pre-approve dental core buildup (D2950). You say that the enrollee needs this dental 
procedure. The Plan denied your request. The Plan says this 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 Plans 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 pre-approve 
dental core buildup on tooth #30.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the hyperbaric oxygen services provided 
from April 6, 2020, to April 17, 2020. 
 
You asked the Plan to waive the copayments for the hyperbaric oxygen services. You say that you were told 
you would pay 20% of the total paid for these services. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing 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 $360 
copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, 
including but not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay a total of $3,465.65 for the hyperbaric oxygen services. The hyperbaric oxygen 
services fall within the ?Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers? benefit category. The record shows you have been charged a $360 
copayment for each date of service. You have been charged a $225.65 copayment on April 17, 2020 because 
you met your maximum out-of-pocket amount of $3,900. 
  
 
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 hyperbaric oxygen services provided from April 6, 
2020, to April 17, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing care (99310) provided. 
 
You asked the Plan to pay for the nursing care (99310). You say that the services were medically necessary. 
The Plan denied your request. The Plan says there were network providers available to perform the 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 nursing care (99310) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for the filling (D2392) and the unspecified 
preventive service (D1999) provided on June 25, 2020. 
 
You asked the Plan to pay the full amount for 2020. You say that you do not understand why you have to pay 
when you have 2 dental policies. The Plan denied your request. The Plan says the provider in this case is out of 
network. The Plan says that there is a 55% coinsurance for fillings that you receive out of network. The Plan 
says that dental services that you receive out of network have a higher cost share. The Plan also says that the 
unspecified preventive service is 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 and fillings are a covered service, there 
is a 55% coinsurance when you receive this service out of network. The Evidence of Coverage clearly states 
that you may be billed by the out of network provider for any amount greater than the payment made by the 
Plan to the provider. Additionally, the unspecified preventive service is not listed as a covered service. 
Therefore, we decided that the Plan does not have to pay the full amount for the filling (D2392) and the 
unspecified preventive service (D1999) provided on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physician services rendered on July 27, 
2020. 
 
You asked the Plan to waive the copayment for these services. You say that the services were a yearly physical 
and should have no copayment. The Plan denied your request. The Plan says the copayment was applied 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for each primary care doctor office visit for Medicare-covered services.  
 
Review of the file shows that you received primary care doctor services on July 27, 2020. The file shows that 
this was a follow-up visit for management of hypertension and hyperlipidemia. You have been asked to pay a 
$15 copayment for these services. These services fall within the primary care doctor office visit for Medicare-
covered 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 copayment for the physician 
services rendered on July 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 4, 2020, by an out-of-
network provider. 
 
You asked the Plan to pay for the medical services. You say that the member had multiple services on the same 
date of service. The Plan denied your request. The Plan says the non-urgent services are not authorized because 
this provider is a non-network provider with the member?s health plan, and another non-network provider with 
the members health plan referred the member for 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 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 July 4, 2020, by 
an out-of-network provider.