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

We decided that the Plan does not have to pay for lab services provided on February 24, 2020. 
 
You asked the Plan to pay for the lab services. You say that the lab reports support the need of procedures 
done. The Plan denied your request. The Plan says Medicare pays for a limited number of Part B services via a 
telecommunications system. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the services ordered following the non-covered visit are likewise 
non-covered. Therefore, we decided that the Plan does not have to pay for lab services provided on February 
24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid service charge and shipping fee you incurred 
on December 20, 2019. 
 
You asked the Plan to pay for the services. You say that this should be covered. The Plan denied your request. 
The Plan says this is not a covered benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays only 
for the hearing aid services listed in the EOC.  
 
We looked at the the file and the Plan's rules. The Plan does not cover service charges and shipping fees for 
hearing aids. You are responsible for the cost of these services. Based on this information, we decided that the 
Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have 
to pay for the hearing aid service charge and shipping fee you incurred on December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit provided on July 27, 2020, by an 
OON provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that you assumed this provider was in-
network because an in-network physician assistant referred you to her. The Plan denied your request. The Plan 
says the treating provider does not participate with your plan. The Plan also says that a prior authorization was 
never requested by you or the OON provider. 
 
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 outpatient office visit provided on July 27, 
2020, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of fingers (73140). 
 
You asked the Plan to pay for an x-ray of fingers. You say that the enrollee had multiple exams on this date. 
The Plan denied your request. The Plan says this was not billed with a modifier that would allow payment. 
 
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, we have confirmed that code 73140 
has a Column One/Column Two relationship with code 73130 and cannot be paid as billed. This code cannot 
be paid without an appropriate modifier.  
 
 
 
 
 
 
 
 
 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for an x-ray of fingers (73140) provided on May 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair and accessories. 
 
You asked the Plan to pre-approve the wheelchair. You say that the manual wheelchair is medically necessary. 
The Plan denied your request. The Plan says a power wheelchair was provided in 2018. No documentation has 
been submitted showing that the power wheelchair is damaged or non-functional. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a Group 2 power wheelchair. A Group 2 power wheelchair serves the same 
purpose as the wheelchair. Therefore, we decided that the Plan does not have to pre-approve a manual 
wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited bilateral noninvasive physiologic studies of upper 
or lower extremity arteries and outpatient office visit provided on December 2, 2019 by an OON provider. 
 
You asked the Plan to pay for the limited bilateral noninvasive physiologic studies of upper or lower extremity 
arteries and outpatient office visit. You say that the treating provider is in network with the enrollee's plan, and 
should not need an authorization for the services. The Plan denied your request. The Plan says these services 
were rendered by a non-participating provider. The Plan also says that prior authorization was not obtained. 
 
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 limited bilateral noninvasive physiologic 
studies of upper or lower extremity arteries and outpatient office visit provided on December 2, 2019 by an 
OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay more for the mental health visit you had on June 9, 2020 with an 
out-of-network provider. 
 
You asked the Plan to pay more for the mental health visit.. You say that you have no issue paying your out-of-
network copayment, but you should have been reimbursed more for the services. The Plan denied your request. 
The Plan says you have been reimbursed the correct amount for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that if a provider accepts Medicare, then they cannot 
bill more than the Medicare-allowed amount for those services.  They are not permitted to balance bill for these 
services. In this case, the provider of these services participates in Original Medicare.  Therefore, they are only 
entitled to be paid the Medicare-allowed amount for these services.  The Medicare-allowed amount for the 
services you received is $89.92.  You have a $50 copayment, which you agree is appropriate.  That means that 
you are entitled to reimbursement of $39.92 ($89.92-$50 = $39.92).  This is the amount that you have been 
reimbursed by the Plan.  The Plan is not required to pay more than this amount.  Please note, however, that 
since this provider accepts Medicare, the provider cannot charge you more than the Medicare-allowed amount.  
You may go back to this provider to request a refund of any amounts paid above and beyond the Medicare-
allowed amount. 
 
We looked at the file and Medicare rules. Based on this information, we decided that that the Plan does not 
have to pay more for the mental health visit you had on June 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental anesthesia.You asked the Plan to pre-approvedental anesthesia. You say that you are in pain.The Plan denied your request. The Plan says coverage criteria have 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 documentation shows that anesthesia was requested for the extraction of teeth #1 and 16. We looked atthe file, and rules. The Plan's policy says that anesthesia is covered for extractions of six or more teeth, two or more quadrants having at least two teeth undergoing the procedure per quadrant, or three or more quadrants having at least one tooth undergoing the procedure per quadrant. The documentation provided does not indicate that the Plan's rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approvedental anesthesia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the requested bed. The Plan denied your request. The Plan says the 
requested bed is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. You say that the enrollee has used the requested drug previously. 
You also say that it provided relief for 10 months. The Plan denied your request. The Plan says the requested 
viscosupplement is not a preferred drug. The Plan says that the requested drug is not medically necessary. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gel-One. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found the criteria has not been met. The 
reviewer found there is no documentation of trial and failure of the first line drugs orthovisc and monovisc. 
Therefore the reviewer found that the requested drug is not medically 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 Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One (J7326).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 2nd opinion with an out-of-network provider. 
 
You asked the Plan to pre-approve a 2nd opinion with an out-of-network provider. You say that you would like 
the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 
neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network OB-
GYN/Oncology specialist's and Interventional Radiology providers available to you that can provide the 2nd 
opinion you are requesting. The Plan says if a referral is needed for tertiary care, this can be arranged as well. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is 
not providing these services and is not making arrangements to provide these services. Therefore, we decided 
that the Plan does not have to pre-approve a 2nd opinion with an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urinalysis provided on June 10, 2020. 
 
You asked the Plan to waive the copayment for the urinalysis. You say that you thought the lab test was 
covered with no 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 $10 for 
Medicare-covered laboratory tests.  
 
You have been asked to pay $3.11, which is less than the standard $10 copayment for the urinalysis. The 
urinalysis 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 the urinalysis provided on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office outpatient visit (99214) and thirty (30) minutes of 
psychotherapy (90833) provided on March 6, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit and psychotherapy. You say that no one told you the provider was 
out-of-network. The Plan denied your request. The Plan says prior authorization must be obtained for non-
emergent services rendered by an out-of-network provider. 
 
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 office outpatient visit (99214) and thirty (30) 
minutes of psychotherapy (90833) provided on March 6, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the measurement of cryofibrinogen (82585), computed 
tomography (CT) of abdomen and pelvis (74177), normal saline solution infusion (J7050) and low osmolar 
contrast material (Q9967) provided on May 29, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for measurement of cryofibrinogen, computed tomography (CT) of abdomen and 
pelvis, normal saline solution infusion and low osmolar contrast material. You say that services rendered were 
medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-
emergent services rendered by an out-of-network provider. 
 
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 measurement of cryofibrinogen (82585), 
computed tomography (CT) of abdomen and pelvis (74177), normal saline solution infusion (J7050) and low 
osmolar contrast material (Q9967) provided on May 29, 2020, by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the knee. 
 
You asked the Plan to pre-approve MRI. You say that you have right knee pain and need an MRI in order to 
have a procedure. The Plan denied your request. The Plan says that the denial of authorization for this service is 
correct, because this test is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that you meet 
the Medicare criteria for the requested MRI. Our physician reviewer found while you have not completed a 
recent course of physical therapy, you do have joint effusion on clinical evaluation. The presence of observable 
joint effusion is of itself a valid indication for MRI absent a trial of physical therapy. X-Rays show evidence of 
severe osteoarthritis of the right knee. Also, this scan is being requested prior to a planned non-arthroscopic 
procedure. With these clinical facts in mind, this MRI is medically 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
Magnetic Resonance Imaging (MRI) of the knee.  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested spinal surgery. 
 
You asked the Plan to pre-approve the requested spinal surgery. You say that the requested spinal surgery is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested spinal surgery. 
 
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 requested spinal surgery. Our 
reviewer says that the enrollee does not meet criteria for the requested spinal surgery. Our physician reviewer 
found this enrollee presents with chronic low back pain and bilateral sacroiliac (SI) joint pain. Clinical exam 
findings have documented positive Faber's test bilaterally. Conservative treatment had included activity 
modification, medications, and sacroiliac joint injections. A recent lumbar MRI evidenced multilevel central 
canal and neuroforaminal stenosis, mild to moderate. Sacroiliac joint injections have reportedly provided 80% 
improvement in pain for 2 weeks, and sustained 40% improvement. He has been diagnosed with bilateral 
sacroiliitis. Under consideration is a request for bilateral SI joint fusion. Medicare coverage criteria have not 
been met. There are no current clinical exam findings of Fortin's point or a cluster of three provocative SI joint 
tests. There are no imaging findings documented relative to the SI joints. There is no documentation of hip x-
rays to rule-out concomitant hip pathology. Therefore, the enrollee does not have a covered indication for the 
requested spinal surgery. 
 
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 requested spinal surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the requested spinal surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sports medicine and rehabilitation services to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the OON sports medicine and rehabilitation services. You say that you were 
injured in a bus accident and your lawsuit was blocked. You say that you will not let the plan tell you who you 
can and cannot go to for your care. You say that the Plan may have been paid off by the bus company who 
blocked your lawsuit. The Plan denied your request. The Plan says it is not medically necessary for the enrollee 
to go out of network for care. The Plan says that a network gap does not exist. 
 
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 provider at issue in this case is not a network provider with the Plan. We looked at the file and Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of the OON sports medicine and 
rehabilitation services have not been met.  
 
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 the OON sports medicine and rehabilitation services. 
Therefore, we decided that the Plan does not have to pre-approve sports medicine and rehabilitation services to 
be provided by an out of network (OON) provider.