Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a connection between two components (E2311). 
 
You asked the Plan to pre-approve a connection between two components. You say that this is medically 
necessary. The Plan denied your request. The Plan says there is not a medical need to control the power options 
through a joystick. 
 
The Plan follows Medicare rules. Medicare rules say that the electronic components that allow the beneficiary 
to control two or more of the following motors from a single interface are covered when medically necessary 
per the above guidelines. 
 
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 a connection between two components. 
Our reviewer says that the requested item is not medically necessary. Our physician reviewer found the 
documentation does not reveal that the requested item is medically necessary to control two or more of the 
following motors from a single interface (e.g., proportional joystick, touchpad, or non-proportional interface): 
power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, power seat 
elevation, power standing 
The patient's upper extremity strength and function are sufficient for the patient to control any power options 
through their own individual switches. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a connection between two components have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a connection between two components (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 4, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee 
must generally must receive your care from a network provider. In most cases, care you receive from anon-
network provider (a provider who is not part of our plan's network) will not be covered. 
 
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 September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility visit (99309) provided on July 
6, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility visit. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 subsequent nursing facility visit (99309) 
provided on July 6, 2020, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and extraction to be provided by an oral 
surgeon. 
 
You asked the Plan to pre-approve the consultation and extraction. You say that you have a broken tooth inside 
of your gum that is infected. You also say that you must be seen by an oral surgeon. The Plan denied your 
request. The Plan says the contract only provides coverage for dental services performed by a participating 
general dentist. The Plan also says that dental services performed by an oral surgeon 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 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 
covered when they are rendered by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a consultation and extraction to be provided by an oral surgeon.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient kyphoplasty at L1 and L4. 
 
You asked the Plan to pre-approve the kyphoplasty. You say that you do not understand why the procedure is 
not medically necessary when there are clearly 3 fractures and your pain says at level 10 except for short 
periods where the pain medication partially helps. The Plan denied your request. The Plan says the enrollee 
does not meet the medical necessity rules for the requested kyphoplasties. 
 
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 kyphoplasty. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the criteria for kyphoplasty not met. There is no imaging evidence of an acute or subacute 
fracture. Also, recent literature shows kyphoplasty is not more effective than sham treatment. It is not 
medically needed. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve outpatient kyphoplasty at L1 and L4.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the periodic oral evaluation, prophylaxis, fluoride varnish application 
and crown provided on June 15, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, fluoride varnish application and crown. 
You say that insurance paid for your previous prophylaxis and exam. You say that insurance should pay for 
this. The Plan denied your request. The Plan says that payment cannot be issued for services performed by a 
provider that has opted out of Medicare. 
 
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. Our review of the Medicare database does not indicate the provider has opted 
out of Medicare. The Plan did not submit any documents showing the provider was an opt out provider at the 
time of service. Therefore, we decided that the Plan has to pay for the periodic oral evaluation, prophylaxis, 
fluoride varnish application and crown provided on June 15, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided 
on May 28, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you only paid a 
$40 copayment in the past and 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received a Medicare Part B drug injection on May 28, 2020. The allowed amount is $1,876.88 and 20% of 
that is $375.38. 
 
You have been asked to pay the total coinsurance amount of $375.38 for a Medicare Part B drug injection. A 
Medicare Part B drug injection falls within the Medicare Part B prescription drugs benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for a Medicare Part B drug injection provided on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient office or other outpatient visit and urinalysis 
test (99204, 81003) provided on April 27, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the new patient office or other outpatient visit and urinalysis test. You say that 
you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says 
prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly 
denied. 
 
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 new patient office or other outpatient visit and 
urinalysis test (99204, 81003) provided on April 27, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit (99202) provided on June 3, 2020, by an out-of-network (OON) provider.You asked the Plan to pay foroffice visit. You say that you were not told you needed prior authorization.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 forthe office visit (99202) provided on June 3, 2020, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided on May 9, 2020. 
 
You asked the Plan to pay for the inpatient care. You say that this was billed correctly for medically necessary 
care. The Plan denied your request. The Plan says this claim was billed without the required condition code to 
indicate that the enrollee was transferred to another hospital on the same day. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to not penalize an enrollee for two days 
of use of covered inpatient days, claims in which the enrollee is transferred to another hospital on the same day 
as admission to the first should be billed with condition code 40. 
 
The file shows that this enrollee was transferred to another hospital on the same day as admission. Condition 
code 40 was not reported on the claim as required. Therefore, we decided that the Plan does not have to pay for 
the inpatient hospital care provided on May 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on April 3, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on April 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 12, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges 
because you were experiencing multiple health issues. 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 $250 
copayment for ambulance services.  
 
You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided on June 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on March 27, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 80156, 80177, 80201, 80159, and 80173 are not supported and code 80162 is not covered as screening. 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 codes 80156, 80177, 80201, 80159, and 80173 are not supported in the medical record. Specifically, there is no documentation of test results via blood specimen. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, digoxin total assay, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.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 pay forthe laboratory services rendered on March 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99213) provided 
March 4, 2020 
 
You asked the Plan to waive the copayment for the outpatient office visit. You say that when you arrived for 
the exam the receptionist noted that it was for your yearly full eye exam and that no copayment was due. The 
Plan denied your request. The Plan says the provider had verified that this was a medical eye exam. Therefore, 
this claim was processed with the correct copayment applied. 
 
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 
copayment for each Medicare covered visit.  
 
You have been asked to pay $20 copayment for the outpatient office visit. The outpatient office visit falls 
within the Vision 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 
outpatient office visit (99213) provided March 4, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on April 16, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says the services are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on April 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided after 2:50 pm on 
March 19, 2020, through March 20, 2020. 
 
You asked the Plan to pay for these services. You say that the inpatient hospital care provided was medically 
necessary. The Plan denied your request. The Plan says the enrollee's emergency medical condition stabilized 
by 2:50 pm on March 19, 2020. Subsequent care was post stabilization care and not approved in compliance 
with the health plan's authorization procedures.  The Plan has paid for all emergent care up to the point of 
stability. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
 
 
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 these services. Our reviewer says that the 
post stabilization of care services provided after 2:50 pm on March 19, 2020, were not medically necessary.  
 
Our physician reviewer found that on March 19, 2020, the enrollee was hemodynamically stable after having 
had a negative nuclear stress test the same day. He was described as being in no acute distress (NAD), had 
demand ischemia, and the cardiologist recommended continued therapy of the paroxysmal supraventricular 
tachycardia (PSVT) with a beta blocker. The enrollee was stable for transfer at 2:50 pm on March 19, 2020. He 
was not transferred back to the skilled nursing facility until the following day on March 20, 2020, to resume 
rehabilitation. There was no documentation provided necessitating continued post-stabilization care services at 
the non-Plan facility after 2:50 pm on March 19, 2020. The review has determined that the treating physician 
did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer 
on any dates of service. 
 
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 pay for the inpatient hospital care provided after 2:50 pm on March 19, 2020, through March 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve parathyroid planar imaging. 
 
You asked the Plan to pre-approve parathyroid planar imaging. The Plan denied your request. The Plan says 
this is 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 parathyroid planar imaging. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee has hypercalcemia, but the medical records do not support a 
diagnosis of primary hyperparathyroidism. A PTH level was ordered, but the results were not provided. 
Without knowing her PTH level, we don't know if her elevated calcium is due to a parathyroid abnormality or 
another underlying condition. There is no reason to obtain a sestamibi scan or planar scan until the diagnosis of 
hyperparathyroidism has been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of parathyroid planar imaging have not been met. Therefore, we decided that the 
Plan does not have to pre-approve parathyroid planar imaging.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray (71045) provided. 
 
You asked the Plan to pay for an x-ray. You say that the enrollee had multiple exams on this date of service. 
The Plan denied your request. The Plan says this was not billed with the required modifier. 
 
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 71045 
has a Column One/Column Two relationship with code 71100, which was previously billed by the same 
provider for the same date of service, and cannot be paid as billed. This code cannot be paid as a separate line 
item 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 (71045) provided.