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

 
We decided that the Plan does not have to pay for the pathology consultation provided on February 11, 2020 
billed with two units of code 88321. 
 
You asked the Plan to pay for the pathology consultation as billed. You say that this should be paid as billed. 
The Plan denied your request. The Plan says this was correctly denied as more than one unit of this service is 
never payable on the same date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. In cases where the MAI of the MUE is 2, 
there is no circumstance in which more than the MUE amount can be paid. 
 
In this case, the MUE for CPT code 88321 is 1, and the MAI is 2. You billed 2 units of this code, exceeding the 
MUE. Based on this information, we decided that Medicare rules for coverage of the pathology consultation as 
billed have not been met. Therefore, we decided that the Plan does not have to pay for the pathology 
consultation provided on February 11, 2020 billed with two units of code 88321.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 11, 2020. 
 
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 on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for radiation therapy services you received 
from April 6, 2020, through April 24, 2020. 
 
You asked the Plan to reduce the copayments for the radiation therapy services. You say that you believe you 
are being double charged for these services. The Plan denied your request. The Plan says you were charged 
these copayments 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 $10 
copayment per day for radiation therapy.  
 
You have been asked to pay a $10 copayment per day for the radiation therapy services. Records show that you 
had radiation therapy in two separate weeks.  You received radiation therapy from April 6, 2020, through April 
9, 2020.  You then received additional radiation therapy from April 14, 2020, through April 24, 2020. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to reduce the copayments for radiation therapy services you received from April 6, 
2020, through April 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the records show the enrollee has a severe infection 
in the belly, trouble with breathing that requires a breathing machine, and an infection in the lungs. The Plan 
says that the enrollee needs to stay in the hospital until she is better. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving, but still requires short term acute care services 
for her various medical conditions. The enrollee does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that are not already available and covered 
at the current facility. It appears appropriate for the enrollee to continue care at the current facility until more 
stable and ready for transfer to a lower level of care. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 16, 
2020. 
 
You asked the Plan to pay for the dental services. You say that your tooth had been bothering you for 6 weeks. 
You say you should not have to wait a year to get it looked at. You also say that you thought you had a certain 
amount of money for dental services each year. The Plan denied your request. The Plan says limited oral 
evaluations are covered once every 3 years. The Plan says that the frequency limit has been exceeded. 
 
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 and limited oral evaluations are a 
covered service, the frequency limit has been exceeded. The record shows that the Plan previously paid for this 
service on February 5, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided on June 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobile x-ray services (71045, Q0092, R0070) provided 
on March 17, 2020. 
 
You asked the Plan to pay for the mobile x-ray services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says there were network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the mobile x-ray services (71045, Q0092, R0070) provided on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office outpatient visit (99213) and radiologic 
examination (X-Ray) of foot (73630) provided on January 23, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit and foot X-Ray. You say that you provided services that should be 
compensated. The Plan denied your request. The Plan says prior authorization must be obtained for non-
emergent services with 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 (99213) and radiologic 
examination (X-Ray) of foot (73630) provided on January 23, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous passive motion (CPM) device rendered on 
January 28, 2020 to February 16, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are 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. 
 
In this case, the CPT Code Manual definition of code E0935 is continuous passive motion exercise device for 
use on knee only. 
 
We find that CPT code E0935 is not supported in the medical record. Specifically, the physician order is for 14 
days and does not support the billed units. 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 
continuous passive motion (CPM) device rendered on January 28, 2020 to February 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 3, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the use of a telecommunications system may substitute 
for an in-person encounter for professional consultations, office visits, office psychiatry services, and a limited 
number of other physician fee schedule (PFS) services. 
 
The file shows that the laboratory services at issue were ordered via telehealth. Medicare does not allow for 
these services to be ordered via telehealth. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99308) provided on September 17, 
2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that you provided medically necessary services in 
good faith. The Plan denied your request. The Plan says prior authorization must be obtained for 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 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 nursing facility care (99308) provided on 
September 17, 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 panoramic x-ray (D0330) provided on June 22, 2020. 
 
You asked the Plan to pay for the dental service. You say that you requested that your records to be sent to the 
provider in this case after your previous dentist retired. You say that they were never transferred. You say that 
you needed a panoramic x-ray to rule out an abscess as you were experiencing severe radiating pain. The Plan 
denied your request. The Plan says panoramic x-rays are limited to coverage once every 3 years. The Plan says 
that the frequency limit has been exceeded. 
 
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 and panoramic x-rays are a covered 
service, they are limited to coverage once every 3 years. The frequency limit for this service has been 
exceeded. The record shows the Plan previously paid for this service on December 4, 2018. Therefore, we 
decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Electroconvulsive Therapy services provided on July 3, 
2019 and July 10, 2019. 
 
You asked the Plan to pay for the Electroconvulsive Therapy services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says your out of network provider 
did not submit medical records to show this treatment was medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. You did not have prior authorization for out of network care. Your provider was 
asked to submit medical records to demonstrate medical necessity for this treatment but did not respond. 
Therefore, we decided that the Plan does not have to pay for the Electroconvulsive Therapy services provided 
on July 3, 2019 and July 10, 2019.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to waive the copayment for lab services you received on May 15, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that you had the blood draw at your 
PCP's office. The Plan denied your request. The Plan says that you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees pay a $0 copayment for lab services received during a PCP office 
visit.  
 
The Plan says you should pay a $20 copayment for the lab services because the doctor?s office sent the lab 
specimen to an out-of-network lab.  This argument is not persuasive.  Your Evidence of Coverage clearly states 
that you have a $0 copayment for labs during a PCP office visit.  The records show that your lab specimen was 
collected during a PCP office visit.  It is not appropriate for the plan to charge you a copayment simply because 
your PCP chose to send the specimen to an out-of-network lab.  It is the plan's obligation to clearly explain 
cost sharing obligations.  There is nothing in your Evidence of Coverage to indicate that you would be 
responsible for a copayment if your PCP sends your specimen to an out-of-network lab. Based on the Plan 
contract, however, you cannot be asked to pay more than a $0 copayment for the lab services. Therefore, we 
decided that the Plan has to waive the copayment for lab services you received on May 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: Favorable

 
We decided that the Plan has to pay for the established patient office or other outpatient visit (99213) provided 
on May 4, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. You say that you have 
been approved at an in-network benefit level for fiscal year 2020. The Plan denied your request. The Plan says 
that the member does not have out-of-network benefits for the out-of-network outpatient office visit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have been met. Specifically, the record shows that the Plan issued approval for the 
out of network provider. The approval letter, dated March 23, 2020, shows that these services were approved 
for the fiscal year 2020. The file does not show that the Plan provided notice that the office visit with the out-
of-network provider would not be covered. Under Medicare rules, this means that the office visit is considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for the established patient office or other 
outpatient visit (99213) provided on May 4, 2020, by an out of network (OON) provider.  
 
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 pay for an ankle orthosis (L1902) provided on July 29, 2019. 
 
You asked the Plan to pay for an ankle orthosis. You say that this was urgently needed. The Plan denied your 
request. The Plan says this was billed with an incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the Place of Service indicates the place in which 
the item is being used.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an ankle orthosis have not been met. Specifically, the record shows that the claim was billed with 
place of service code 7 (Free-standing Facility). The ankle orthosis is primarily used in the enrollee's home. 
This means that the billed place of service code is not supported. Therefore, we decided that the Plan does not 
have to pay for an ankle orthosis (L1902) provided on July 29, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided by a 
participating provider on February 4, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that your mother passed away and 
you do not feel like she should be charged for ambulance services since no basic life support services were 
provided. 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $150 copayment for ambulance services/ground.  
 
The enrollee has been asked to pay a $150 copayment for ambulance services. The correct copayment has been 
applied to these services. Ambulance services falls within the ambulance services/ground benefit category. This 
means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided 
that the Plan does not have to waive the copayment for ambulance services provided by a participating provider 
on February 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Palonosetron (J2469). 
 
You asked the Plan to pre-approve Palonosetron. You say that the medication is necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Palonosetron. Our reviewer says that 
the medication is not medically necessary. Our physician reviewer found the combination of paclitaxel (taxol) 
and bevacizumab carries a low emetic risk and Palonsetron is used for moderate to high emetic risk. The 
enrollee's notes report some nausea but later state no nausea. Therefore, there is no clear indication for the use 
of Palonsetron. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Palonosetron have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Palonosetron (J2469).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician telephone patient service (99442) provided on 
May 18, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for telephone services by physician. You say that you did not know the provider was 
out-of-network. The Plan denied your request. The Plan says non-emergent services must be provided in-
network unless prior authorization was 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 physician telephone patient service (99442) 
provided on May 18, 2020 by an out of network (OON) provider.