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

 
We decided that the Plan does not have to pre-approve a full back MRI to be provided by the out-of-network 
provider. 
 
You asked the Plan to pre-approve the full back MRI to be provided by the out-of-network provider. The Plan 
denied your request. The Plan says the member is contractually required to obtain this service 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 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 a full back 
MRI to be provided by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth physician services provided on June 17, 2020 
by an out of network provider. 
 
You asked the Plan to pay for the telehealth physician services. You say that authorization should not be 
needed under telemedicine for payment of service rendered. The Plan denied your request. The Plan says you 
did not request 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 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 telehealth physician services provided on June 17, 2020 by an out of network 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nasal endoscopy you received at an 
outpatient hospital facility on August 19, 2019. 
 
You asked the Plan to waive the copayment for the nasal endoscopy. You say that you believe the provider is 
over-charging to simply look up your nose. The Plan denied your request. The Plan says you were charged this 
copayment correctly. The Plan says that since the allowed amount for the endoscopy ($245.71) is less than your 
copayment obligation, you are responsible for this full 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 $295 
copayment for outpatient surgery or other services provided at an outpatient hospital facility.  
 
You have been asked to pay up to a $295 copayment for the nasal endoscopy. The nasal endoscopy falls within 
the outpatient surgery or other services provided at an outpatient hospital facility 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 nasal endoscopy you received at an outpatient hospital facility on 
August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dermatology services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve dermatology services. You say that you would like approval for these 
services. The Plan denied your request. The Plan says there are in-network providers available. 
 
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 
dermatology services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a handheld shower head. 
 
You asked the Plan to pre-approve the requested time. You say that the enrollee would be better assisted during 
her bath time. The Plan denied your request. The Plan says the item is not primarily used for a medical purpose. 
 
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 pre-approve a handheld shower head.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), 
bitewing x-rays (D0274), and the panoramic x-ray (D0330) provided on July 22, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the dentist was out of 
network. You say that you have been seeing this dentist for 12 years. You also say that you were not advised 
that the services would not be covered. The Plan denied your request. The Plan says the provider in this case is 
not a network provider. The Plan also says dental services that you receive out of network are not covered. 
 
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 dental services you received are not 
among those covered under this benefit when you receive them out of network. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), bitewing x-rays 
(D0274), and the panoramic x-ray (D0330) provided on July 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for ambulance transport provided on June 18, 
2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says the contract is clear that there is a copayment for each ambulance 
transport. 
 
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 $250 
copayment for ambulance transport. 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 cost share for ambulance transport provided on 
June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from February 27, 2020 to 
March 5, 2020 and billed under codes 99203, G8942 and G8730. 
 
You asked the Plan to pay for chiropractic services. You say that the Plan should cover these services. The Plan 
denied your request. The Plan says the Plan can only cover those services related to manual manipulation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services provided from February 27, 2020 to March 5, 2020 and billed under codes 99203, G8942 and G8730.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoscopic decompression of spinal cord. 
 
You asked the Plan to pre-approve endoscopic decompression of spinal cord. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
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 endoscopic decompression of spinal 
cord. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has chronic lumbar pain, radiculopathy, and 
spinal stenosis with neurogenic claudication. Endoscopic decompression of the spinal cord is experimental at 
this time. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria 
for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endoscopic decompression of spinal cord have not been met. Therefore, we 
decided that the Plan does not have to pre-approve endoscopic decompression of spinal cord.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from June 29, 2020, to 
July 1, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that these drugs were not self-administered, 
because you needed help to receive the medications. You also say that you should not be responsible for paying 
for the self-administered drugs. The Plan denied your request. The Plan says the drugs you received are self-
administered medications not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from June 29, 2020, to July 1, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the automatic external defibrillator (AED) 
you received on June 30, 2020. 
 
You asked the Plan to reduce the coinsurance for the AED. You say that if you had not used the AED, you 
would have had to stay in the hospital longer and it would have cost the Plan more money. The Plan denied 
your request. The Plan says you were charged this coinsurance 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the AED. The AED falls within the durable medical 
equipment benefit category. This cost sharing applies even if it prevented the need for other medical services. 
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 reduce the coinsurance for the automatic external defibrillator (AED) you received on 
June 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy to be provided by the out-of-network 
provider. 
 
You asked the Plan to pre-approve the panniculectomy to be provided by the out-of-network provider. The Plan 
denied your request. The Plan says the Plan covers services with providers outside of your network only when 
your medical needs cannot be met in-network. 
 
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 a 
panniculectomy to be provided by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient provider services provided July 19, 2018. 
 
You asked the Plan to pay for the inpatient provider services. You say that you have attached your computer 
generated filing report which shows that you sent this claim on 08/10/2018. The Plan denied your request. The 
Plan says the initial claim submission was not filed within 12 months from the original date of service 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the inpatient provider services was not filed until June 16, 2020. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the inpatient provider services provided July 19, 2018.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgical procedures provided 
on May 20, 2020 and June 4, 2020. 
 
You asked the Plan to waive the copayment for the laryngoscopy (31575). You say that you were not told you 
had a copayment every time you went. The Plan denied your request. The Plan says you were charged this 
copayment 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 $325 
copayment for Hospital Outpatient Facilities and Ambulatory Surgical Centers. 
 
You have been asked to pay a $156.28 copayment for each of the laryngoscopies (31575), which is less that 
your required copayment. The laryngoscopies (31575) fall within the 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 the 
outpatient surgical procedures provided on May 20, 2020 and June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you feel comfortable with this provider. 
The Plan denied your request. The Plan says there are in-network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
specialist services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Zoster (shingles) vaccine (90750) vaccine administration 
(90471) provided March 3, 2020. 
 
You asked the Plan to pay for the vaccine. You say that review of the medical records confirms the claim is 
coded correctly. The enrollee encountered for immunization and physician had administered zoster 
recombinant vaccine to the enrollee. The Plan denied your request. The Plan says this is not a covered Part B 
drug or service 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pay for Zoster (shingles) vaccine (90750) vaccine administration (90471) provided 
March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient provider services  provided July 19, 2018 to 
July 20, 2020. 
 
You asked the Plan to pay for the inpatient provider services. You say that you have attached your computer 
generated filing report which shows that you sent this claim on 8/10/2018. The Plan denied your request. The 
Plan says the claim was not submitted within 12 months of the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the inpatient provider services was not filed until June 16, 2020. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the inpatient provider services  provided July 19, 2018 to July 20, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit option for the Sunrise Quickie Iris tilt-in-space 
manual wheelchair. 
 
 
You asked the Plan to pre-approve the transit option. You say that this is medically necessary. The Plan denied 
your request. The Plan says durable medical equipment coverage is limited to what can be used inside the 
home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
A transit option is for use outside of the home. Although this item may be helpful, neither Medicare nor the 
Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-
approve a transit option for the Sunrise Quickie Iris tilt-in-space manual wheelchair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for x-ray services you received on January 14, 
2020. 
 
You asked the Plan to waive the deductible for the x-ray. You say that since the health plan gave you incorrect 
information, you shouldn't be responsible for the bill. The Plan denied your request. The Plan says you were 
assessed this deductible correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible that must be met before the Plan will cover your 
medical care. 
 
This deductible applies to x-ray services. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $250 deductible. This cost sharing is a contractual obligation that had not been met at the 
time the x-ray was received on January 14, 2020. Therefore, we decided that the Plan does not have to waive 
the deductible for x-ray services you received on January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided from May 13, 2019 to June 
10, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 the laboratory services are not supported in the medical record. Specifically, the place of service 
on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The 
submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; 
however, the 
submitted medical documentation and/or claim history indicates that the specimen was obtained in an inpatient 
skilled nursing care facility place of service 31; therefore, the billed codes cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided from May 13, 
2019 to June 10, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve the additional mileage. You say that this is medically necessary. The Plan 
denied your request. The Plan says the request exceeds the mileage benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers routine transportation up to 50 miles one-way. 
 
We looked at your request, the records in the case file, and the rules. you are requesting a trip that 154 miles 
one-way. This 104 miles over the limit. Based on this information, we decided that the Plan?s rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional routine transportation mileage.