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

 
We decided that the Plan does not have to pre-approve the oncology consult (99205, 99215) to be provided by 
an out of network provider. 
 
You asked the Plan to pre-approve the oncology consult. You say that you would like to continue to see the 
provider the performed your surgery. The Plan denied your request. The Plan says there are in-network 
oncology specialists that can provide the services at issue. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
oncology consult (99205, 99215) to be provided by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81545) provided on June 27, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for OON laboratory services. You say that this is a covered service. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 laboratory services (81545) provided on June 
27, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges. 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 $160 
copayment for ultrasounds.  
 
You have been asked to pay the allowed amount of $80, which is less than the $160 copayment for an 
ultrasound. An ultrasound falls 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 copayment for an ultrasound provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 17, 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 March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care services provided on December 22, 
2019 billed with code 99223. 
 
You asked the Plan to pay for the initial hospital care services. You say that these services should be paid. The 
Plan denied your request. The Plan says code 99223 was already paid for the services rendered by this 
provider. As such, this second claim was correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that only one unit of code 99223 can be paid per day 
to the same provider. 
 
In this case, we have confirmed that the services described by code 99223 were covered by the Plan for this 
date of service. As such, another unit of 99223 is not payable. Therefore, we decided that the Plan does not 
have to pay for the initial hospital care services provided on December 22, 2019 billed with code 99223.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a laryngoscopy provided on July 14, 2020. 
 
You asked the Plan to waive the copayment for a laryngoscopy. You say that you were never informed of the 
charges and cannot afford them. 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 $325 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
You have been asked to pay the allowed amount of $155.18, which is less than the $325 copayment, for a 
laryngoscopy. A laryngoscopy falls within the outpatient surgery and other medical services provided at 
hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a laryngoscopy provided on July 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement and late closure of wound provided on July 
28, 2020. 
 
You asked the Plan to pay for the debridement and late closure of wound. You say that the assistant surgeon 
services were in the best interest of the enrollee. The Plan denied your request. The Plan says these codes have 
an indicator of 1 and are excluded from payment. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 
11043, 13160. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This 
means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. 
Based upon this information, we find that Medicare coverage criteria for the debridement and late closure of 
wound have not been met. Therefore, we decided that the Plan does not have to pay for the debridement and 
late closure of wound provided on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 4, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 
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 February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on July 14, 2020. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says this provider will not submit medical records for review, and you did not 
have prior authorization for out of network care. 
 
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 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 out of network physician 
services provided on July 14, 2020.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a colonoscopy provided on July 28, 2020. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you should not owe a copayment 
for colonoscopies. The Plan denied your request. The Plan says that the claims were processed correctly and 
you are being charged the correct amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records. Without medical records we cannot 
determine whether or not the colonoscopy was diagnostic or preventative. Therefore, we decided that the Plan 
has to waive the copayment for a colonoscopy provided on July 28, 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 pre-approve the RESPeRATE device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not primarily used for a medical purpose, and does not treat illness or injury. 
 
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 device. Our reviewer says that the 
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the records provided and Social Security Act, Section 1862 (a)1(A) and the 42 CFR ?411.15(k) 
there is no documentation that the RESPeRATE device at issue in this case medically reasonable and 
necessary. There are no available medical records documenting that the device is reasonable and necessary or 
that the device meets the required criteria as detailed in the Social Security Act, Section 1862 (a)1(A) and the 
42 CFR ?411.15. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the RESPeRATE device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee. 
 
You asked the Plan to pre-approve the spacer. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered and 
investigational. 
 
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 spacer. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the spacer is experimental. More research is needed to show safety and efficacy. 
 
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 spacer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Superion interspinous spacer for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the denture reline (D5751) provided on June 22, 2020. 
 
You asked the Plan to pay for the dental service. You say that it is difficult, if not near impossible, to determine 
what dental services are covered by your policy. You say that you do not know what is covered until after you 
have received the service. You also say that this puts a financial hardship on you. The Plan denied your request. 
The Plan says the denture reline is not listed as a covered service. The Plan also says that you are responsible 
for the cost of the service. 
 
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 denture reline is not among those 
covered under this benefit. The record shows that you were advised by a plan representative that you were only 
covered for oral exams, cleanings, fluoride treatment, and x-rays. Therefore, we decided that the Plan does not 
have to pay for the denture reline (D5751) provided on June 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on March 
21, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the claim does not show 
the $200 copayment. The Plan denied your request. The Plan says you are referring to a claim number in this 
appeal request that is a duplicate claim and rejected as this and a copay is not applying for this reason. The Plan 
states the original claim processed correctly, therefore, they will not make any adjustments to your claim. 
 
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 the ambulance services 
on March 21, 2020. The original claim was processed correctly and you were assessed a $200 copayment for 
the ambulance services. The claim you are referring to in this appeal is a duplicate. Therefore, the original 
claim has your $200 copayment. 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 ambulance services 
provided on March 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray performed April 27, 2020. 
 
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the claim included an invalid place of service. 
 
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 71045 is not supported in the medical record. Specifically, the claim was submitted 
with place of service 23 which indicates Emergency care, however the service was billed with a screening 
diagnosis code. Based on this information, we decided that Medicare rules for coverage of the x-ray have not 
been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray performed April 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all lower extremity prostheses, multi-axial rotation 
unit (L5986). 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested prosthetic component cannot be covered as the incorrect code is used. 
 
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 these services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. The 
documentation notes that the patient was approved for an L5986 x 1 multi axial rotation unit already and a 
duplicate service is not considered medically necessary. Our physician reviewer found that your condition does 
not meet Medicare criteria for coverage of an all lower extremity prostheses, multi-axial rotation unit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an all lower extremity prostheses, multi-axial rotation unit (L5986).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided on July 7, 
2020. 
 
You asked the Plan to pay for comprehensive oral evaluation. You say that the service should be covered. The 
Plan denied your request. The Plan says you exceeded your maximum frequency for this 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. This benefit includes one 
comprehensive exam every 3 plan years. 
 
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. Specifically, you have already exhausted your maximum frequency for 
this benefit. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation 
(D0150) provided on July 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the device is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Superion device for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging, 
tomographic (SPECT) provided on August 26, 2020. 
 
You asked the Plan to waive the copayment for the radiology service. You say that you should have been 
advised of the copays prior to testing. 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 a myocardial perfusion imaging, tomographic (SPECT) provided on August 26, 2020. You 
are asked to pay a $250 copayment per day for Medicare-covered diagnostic radiology services. Your EOC 
states that enrollees must pay a $250 copayment per day for Medicare-covered diagnostic radiology services 
($100 ultrasound). 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 myocardial perfusion imaging, 
tomographic (SPECT) provided on August 26, 2020.