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

We decided that the Plan does not have to pre-approve facet joint injections (CPT Codes: 64494 X2, 64495 X4, 
and 64493 X2). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the Medicare criteria have not been met. 
 
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 services. Our physician reviewer 
found there is documentation of radiculopathy. The medical records provided do not meet the requirements 
listed in the LCD for Medicare coverage. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections (CPT Codes: 64494 X2, 64495 X4, and 64493 X2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth services provided on June 1, 
2020. 
 
You asked the Plan to waive the copayment for the telehealth services. You say that if you have to pay a copay 
it better be for an office visit not a phone call. 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 $25 
copayment for Medicare covered telehealth services.  
 
You have been asked to pay a $25 copayment for the telehealth services. The telehealth services fall within the 
Medicare covered telehealth 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 
the telehealth services provided on June 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 18, 
2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says you generally must receive your care from a 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 laboratory services provided to the enrollee on 
December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided by a participating 
provider on July 24, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that you went for your annual wellness 
exam. The Plan denied your request. The Plan says the correct copayment has been 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 a $15 
copayment for physician/practitioner services/primary care physician.  
 
You have been asked to pay a $15 copayment for an office visit. When services are provided that go beyond an 
annual wellness exam, additional copayments can be applied; therefore, the correct copayment has been 
applied. An office visit falls within the physician/practitioner services/primary care physician benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an office visit provided by a participating provider on July 
24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided on October 16, 2019 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for a walk-in bathtub and a new hot water heater. You say that this is being 
incorrectly denied. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan 
says that the company that provided these services are no contracted with the Plan; 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 durable medical equipment provided on October 
16, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided 
on July 21, 2020. 
 
You asked the Plan to pay for the topical application of fluoride varnish. You say that a Plan representative 
advised that you could receive a fluoride treatment with a special coating. The Plan denied your request. The 
Plan says this service is not listed as a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
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 
topical application of fluoride varnish (D1206) provided on July 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the charges for the surgical procedure and self-administered 
drugs provided during an outpatient hospital stay from May 21, 2020 to May 22, 2020. 
 
You asked the Plan to adjust the charges for the surgery and drugs. You say that you are not sure why the drugs 
you received were not covered and why one of the stent you were provided appears to have been denied. You 
feel you should not be billed for these items. The Plan denied your request. The Plan says you were correctly 
assessed a $350 copayment for the surgery. The self-administered drugs were correctly denied as these are not 
eligible for coverage by Medicare Part B. 
  
The Plan must follow Medicare rules. Medicare rules say that self-administered drugs are not covered by 
Medicare Part B, apart from the limited exceptions above. The rules also say that Plans must clearly and 
accurately describe cost sharing applicable to covered services. Your contract clearly states that there is a $350 
copayment for outpatient surgery in the hospital setting. 
 
In this case, we find you were correctly assessed the $350 copayment for the surgery you received. In addition, 
during this hospital stay, you were provided with drugs that are usually self-administered by those who take 
them. These were not used as supplies during that outpatient procedure itself. Medicare Part B cannot make 
payment for drugs provided in this setting. Therefore, we decided that the Plan does not have to adjust the 
charges for the surgical procedure and self-administered drugs provided during an outpatient hospital stay from 
May 21, 2020 to May 22, 2020.  
 
Benefits for the surgery and 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 pre-approve tie down hardware, a power seat elevation system, and 
attendant control for a power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation system and attendant 
control provided in addition to a beneficiary-operated drive control system are non-covered. The rules say that 
equipment for use outside of the home is denied. 
 
We looked at the file and Medicare rules. The power seat elevation system is denied by Medicare as non-
covered. The attendant control is being requested in addition to a beneficiary-operated drive control system and 
is not covered.  
 
 
 
The tie down hardware is for use outside of the home and Medicare does not cover equipment for use outside 
of the home. Therefore, we decided that the Plan does not have to pre-approve tie down hardware, a power seat 
elevation system, and attendant control for a power wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on October 5, 
2019. 
 
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 they verified with their Coordination of Benefits Team on August 25, 2020, that primary 
insurer named above was the enrollee's primary insurer from March 01, 2019, to December 31, 2019.The Plan 
determined they were the secondary insurer at that time. The Plan says that per the above Medicare regulations, 
this claim must be reviewed by the primary first and provide an explanation of benefits to the secondary if 
further review is needed.  
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. The Plan has met its obligation with 
regards to coordination of benefits. Specifically, the Plan has identified the primary insurer and instructed steps 
for claim submission. As the secondary insurer, the Plan cannot be held responsible for this service until the 
primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to 
pay for physician services provided to the enrollee on October 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided, by an OON provider.

You asked the Plan to pay foran electrocardiographic recording, analysis, and report. You say that the enrollee's treatment was unknowingly ordered out-of-network.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 forthe medical services provided, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology testing (81206, 81162, 81275, 81276, 
81292, 81295, 81298, 81301, 81317, 81404) provided on March 2, 2020. 
 
You asked the Plan to pay for molecular pathology testing. You say that this was necessary for personalized 
care. The Plan denied your request. The Plan says this testing was beyond the scope of medical necessity. 
 
The Plan follows Medicare rules. Medicare rules say that for testing panels, including but not limited to, 
multiple genes or multiple conditions, and in cases where a tiered approach/method is clinically available, 
testing would be covered only for the number of genes or test that are reasonable and necessary to obtain 
necessary information for therapeutic decision making. 
 
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 molecular pathology testing. Our reviewer 
says that the criteria for coverage of these tests have not been met. Our physician reviewer found this testing 
for stage III pancreas cancer provides no benefit to the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of molecular pathology testing have not been met. Therefore, we decided that the 
Plan does not have to pay for molecular pathology testing (81206, 81162, 81275, 81276, 81292, 81295, 81298, 
81301, 81317, 81404) provided on March 2, 2020.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the air ambulance services provided on April 29, 2020. 
 
You asked the Plan to pay for the air ambulance services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that it was not medically necessary for the enrollee to be 
transported by air ambulance. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 the air ambulance services. Our reviewer 
says that the service was medically necessary. Our physician reviewer found the enrollee needed Neurosurgical 
care that was not available at the referring facility. The enrollee was judged by the referring physician to 
require air ambulance transport due to severity of illness, and need for timely care. Despite the short distance, 
time is critical with intra cerebral hemorrhage especially in setting of coagulation disorder. The air ambulance 
was the best option given the potential need for emergent surgery. Denial overturned. 
 
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 air ambulance services have been met. Therefore, we decided that the Plan 
has to pay for the air ambulance services provided on April 29, 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve MetroCream for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is 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 pre-approve MetroCream for the 
enrollee.  
 
Benefits for this drug 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided to the enrollee from 
August 13, 2020, to August 14, 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. 
 
Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says 
that outpatient hospital services require prior authorization. The Plan did not pre-approve the services in 
question. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided to 
the enrollee from August 13, 2020, to August 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, the health plan?s denial should be upheld. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a 
lower level of care (ex. SNF/SAR). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 3, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says members 
must use network providers to get medical care and services. The only exceptions are emergencies, urgently 
needed services when the network is not available, and cases in which the Plan authorizes use of out-of-
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 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 on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for new patient home services provided on June 12, 2020. 
 
You asked the Plan to pay for the new patient home services. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or facility. 
 
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 
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 new patient home services provided on June 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided to the enrollee on April 8, 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 Laboratory test results were not submitted; therefore, the billed service cannot be 
verified. It is noted, multiple attempts were made to obtain additional information from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and provide medical records to support the services 
billed. In this case, insufficient records were submitted to support the services billed. Medicare rules for 
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for drug 
testing provided to the enrollee on April 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI scan of the abdomen (74183) 
received on May 28, 2020. 
 
You asked the Plan to waive the copayment for an MRI scan of the abdomen. You say that you do not have the 
money to pay this charge. The Plan denied your request. The Plan says the correct copayment was 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 a $215 
copayment for each procedure for magnetic resonance imaging.  
 
You have been asked to pay a $215 copayment for an MRI scan of the abdomen. An MRI scan of the abdomen 
falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an MRI scan of the abdomen (74183) received on May 28, 2020.  
 
Your complaint about receiving erroneous or misleading information about your cost-sharing responsibility is 
not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.