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

 
We decided that the Plan does not have to waive the copayment for the SNF provided from March 24, 2020, 
through May 8, 2020. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you were in the hospital for 60 days 
and never received information about coverage. You say that you are not in a great financial condition and 
want the claim paid by insurance. The Plan denied your request. The Plan says the copayment 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 $0 
copayment per day, days 1 to 20 and a $178 copayment per day, days 21 to 100 at an in-network skilled 
nursing facility.  
 
 
  
 
 
You have been asked to pay a total of $3,984.43 for the SNF stay.  
 
Date of Service SNF Days Number of Days Copayment Member Liability 
March 24, 2020-
March 31, 2020 
1-8 8 $0/Day $0 
April 1, 2020- 
April 12, 2020 
9-20 12 $0/day $0 
April 13, 2020- 
April 30, 2020 
21-38 18 $178/day $3,204 
May 1, 2020-May 
8, 2020 
39-45 7 $178/day $780.43-Met Max 
Out-Of-Pocket 
TOTAL:    $3,984.43 
 
The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the SNF provided from March 24, 2020, through May 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient behavioral health services rendered by the out 
of network (OON) provider from May 25, 2020, through May 29, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 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 inpatient behavioral health services rendered by the out of network (OON) 
provider from May 25, 2020, through May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on August 5, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee 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 physician services provided 
to the enrollee on August 5, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a repeat echo with Doppler.
You asked the Plan to pre-approve echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography (93306). You say that the repeat echo is medically necessary. The Plan denied your request. The Plan says that the clinical information does not meet criteria for a repeat echocargiogram.
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 echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography (93306). Our reviewer says that the requested service is considered medically reasonable and necessary in this case. Our physician reviewer found as there is some significant discrepancy in the aortic root measurements and at least some reported increase in aortic root size between 2015 and 2018 noted, a repeat echocardiogram with good measurements of the root would be reasonable and useful to firmly re-assess aortic root size. If the aortic root is again reportedly normal or unchanged, further yearly studies would be less necessary. The CMS medical necessity general criteria for the use of ultrasound would support its use in this clinical situation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography (93306) have been met. Therefore, we decided that the Plan has to pre-approve a repeat echo with Doppler.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on July 26, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 26, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 8, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 8, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device with sleeves provided on 
June 22, 2020. 
 
You asked the Plan to pay for pneumatic compression device. You say that you are appealing with records. The 
Plan denied your request. The Plan says the denial of payment for these items is correct, because these items do 
not meet the Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device coded as E0651 
is covered only following a failed six-month trial of conservative therapy as described in the previous section.  
 
We looked at the file and Medicare rules. The documentation does not show that a six-month trial meeting all 
of the required criteria was attempted and failed prior to the furnishing of this pneumatic compression device. 
Based on this information, we decided that Medicare rules for coverage of pneumatic compression device have 
not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device 
with sleeves provided on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a 3D rendering with interpretation (76376) provided July 22, 2020.
You asked the Plan to pay for the 3D rendering with interpretation. You say that the service was medically necessary. The Plan denied your request. The Plan says the billed CPT code is not supported.
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 76376 is not supported in the medical record. Specifically, the interpretation is denied because a qualifying primary service was not identified or allowed on the claim. Based on this information, we decided that Medicare rules for coverage of the 3D rendering with interpretation have not been met. Therefore, we decided that the Plan does not have to pay for a 3D rendering with interpretation (76376) provided July 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft (D7953) and non-intravenous 
sedation (D9248). 
 
You asked the Plan to pre-approve bone replacement graft and non-intravenous sedation. You say that the 
services you are requesting are medically necessary. The Plan denied your request. The Plan says the services 
are not covered under your supplemental dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
replacement graft (D7953) and non-intravenous sedation (D9248).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided.
 
You asked the Plan to pay for the laboratory 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 
laboratory 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 laboratory services provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided. 
 
You asked the Plan to pay for the dental services. You say that the provider advised that these services are not 
covered. You say that had the provider's office not confirmed that the services would be paid, you would have 
cancelled your appointment. You say that you either have to pay for these services with this provider or go to 
another pay for them. The Plan denied your request. The Plan says panoramic 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 panoramic x-ray is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-
ray (D0330) provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran x-ray of the sinuses (70220) provided on August 7, 2020.You asked the Plan to pay foran x-ray of the sinuses. You say that this was billed correctly.The Plan denied your request. The Plan says this is not an appropriate test for allergic rhinitis.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for an x-ray of the sinuses. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found it is rare that imaging would be required for the diagnosis of allergic rhinitis. The Academy of Otolaryngology does not support using imaging when treating a patient for allergic rhinitis. The documentation does not indicate that there was another reason this patient had an x-ray done. Basedon the diagnosis of allergies, the x-ray is not medically necessary or indicated.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an x-ray of the sinuses have not been met.Therefore, we decided that the Plan does not have to pay foran x-ray of the sinuses (70220) provided on August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 23, 2020, by an 
OON provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that these services were rendered in 
good faith to the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 March 23, 2020, 
by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe unlisted neurological or neuromuscular diagnostic procedure  coded 95999 provided on December 10, 2019.You asked the Plan to pay forthe unlisted neurological or neuromuscular diagnostic procedure. You say that you would like the plan to reconsidertheir denial.The Plan denied your request. The Plan says the services billed are not separately payable.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 95999 is Unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, the documentation shows thattrain of four testing was provided. This service is included in the cost of the primary procedure. Based on this information, we decided that Medicare rules for coverage of the unlisted neurological or neuromuscular diagnostic procedure have not been met.Therefore, we decided that the Plan does not have to pay forthe unlisted neurological or neuromuscular diagnostic procedure  coded 95999 provided on December 10, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lumbar injection provided on August 21, 2020.
You asked the Plan to waive the copayment for the lumbar injection. You say that you had the procedure in a
regular office and should not be billed a $375 copayment. The Plan denied your request. The Plan says the
copayment 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 $375
copayment per date of service at a preferred outpatient hospital facility.
You have been asked to pay a $375 copayment for the lumbar injection. The lumbar injection falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The records show that the lumbar injection was billed by the hospital. 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 lumbar injection provided on August 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular risk assessment testing (81286, 81404, 81407, 
81408, 81479) provided on May 15, 2020. 
 
You asked the Plan to pay for cardiovascular risk assessment testing. You say that this was medically 
necessary. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that deny coverage for all cardiovascular (CV) risk 
assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with 
suspected or documented CV disease because panel testing is not specific to a given patient?s lipid abnormality 
or disease. 
We looked at the file and Medicare rules. The services at issue are not covered. Based on this information, we 
decided that Medicare rules for coverage of cardiovascular risk assessment testing have not been met. 
Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing (81286, 
81404, 81407, 81408, 81479) provided on May 15, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

You asked the Plan to pre-approvee pidural injections. You say that you are appealing based on medical necessity.The Plan says that the denial of authorization for these services is correct, because these epidural steroid injections are not medically necessary.

We decided that the Plan has to pre-approve one level of bilateral epiduralsteroid injections, but not a second level of bilateral epidural steroid injections. The Plan follows Medicare rules. Medicare rules say that epidural injections may be covered under certain indications, but no more than 2 injections may be performed at a single setting.

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 epidural. Our reviewer says that you meet the criteria for one level of bilateral epidural injections, but not a second level. Our physician reviewer found you have chronic lower back pain and are taking Meloxicam for pain. You had facet joint blocks without improvement in pain. Magnetic Resonance Imaging (MRI) shows multi-level degenerative disc disease. You had prior epidural steroid injections which produced 75% pain relief. However, this request exceeds the Medicare utilization criteria; therefore,only one level of bilateral epidural steroid injections is considered reasonable and 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 one level of epidural steroid injections have been met, but not a second level. Therefore, we decided that the Plan has to pre-approve one level of bilateral epidural steroid injections. 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 24, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were informed that this service is 
covered. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 24, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral complete series of x-rays (D0210) provided on September 30, 2020.
You asked the Plan to pay for the dental service. You say that you have had 2 dental cleanings twice a year for your whole life. You say that due to Covid-19, you have been denied that. You also say that you do not understand why the insurance can pass the savings on or use your allowance. The Plan denied your request. The Plan says the intraoral complete series of x-rays is not listed as a covered service. The Plan also says that the dentist provided a signed treatment plan where you agreed to be responsible for all services rendered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral complete series of x-rays (D0210) provided on September 30, 2020.