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

 
We decided that the Plan does not have to pay for the drug testing services provided on July 19, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for drug testing services. You say that the services are medically necessary and was 
not aware of the requirements of obtaining a prior authorization. The Plan denied your request. The Plan says 
there is no prior authorization on file for these services and can be obtained from an in-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 had network providers 
available who could have provided 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 drug testing services provided on July 19, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service August 10, 
2022. 
 
You asked the Plan to pay for procedure code 97010. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 97010 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service August 10, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for discharge management provided on September 2, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for discharge management. You say that the records support this service The Plan 
denied your request. The Plan says out-of-network providers will not be covered unless authorized. 
 
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 had network providers 
available who could have provided 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 discharge management provided on September 2, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided on June 30, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for drug testing services. You say that you feel these services are medically 
necessary. The Plan denied your request. The Plan says there is not an authorization on file for the services. 
 
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 had network providers 
available who could have provided 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 drug testing services provided on June 30, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 29, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied as the claim was filed 
untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a claim for the dental services was not filed until July 17th, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for dental services provided on January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D2740, D0220, D0140) provided on May 
18, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services (D2740, D0220, D0140) provided on May 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One 30mg/3 mL intra-articular syringe. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says it is not medically necessary to have a step therapy exception. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that based on the 
medical records provided, there is no indication that the enrollee has tried and failed the required drug. Based 
on the medical records provided and the Medicare-approved major drug compendia there is no indication that 
the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One 30mg/3 mL intra-articular syringe.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 25, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service August 25, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for inpatient mental health care services provided from 
June 11, 2022, to June 12, 2022. 
 
You asked the Plan to waive or reduce the copayment for the inpatient mental health care. You say that you 
feel the cost should be waived or reduced as you did not agree to the treatment. The Plan denied your request. 
The Plan says that this cost sharing was charged 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 must pay a $250 copayment per day for days 1-4 for inpatient mental 
health care.  
 
The Plan says you must pay a $250 copayment per day for 2 days for the inpatient mental health care, for a 
total of $500. Based on the Plan contract, however, you cannot be asked to pay more than a $250 copayment 
per day for 1 day for the inpatient mental health care, as the copayment does not apply to the discharge date. 
Therefore, we decided that the Plan has to reduce the copayment for inpatient mental health care services 
provided from June 11, 2022, to June 12, 2022, to $250.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear provided on July 7, 2022. 
 
You asked the Plan to pay for the eyewear. You say that you could not find a pair of eyeglasses under $200 in-
network. You say you went out-of-network in order to stay under the Plan allowance. The Plan denied your 
request. The Plan says the benefit does not apply to out-of-network providers.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we 
decided that the Plan does not have to pay for the eyewear provided on July 7, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on June 29, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $100 
copayment for each emergency room visit. If you are immediately admitted to the hospital, your cost-sharing 
amount for the emergency room visit will be waived. Emergency care refers to services that are: Furnished by a 
provider qualified to furnish emergency services, and needed to evaluate or stabilize an emergency medical 
condition. 
 
 
 
 
 You have been asked to pay a $100 copayment for emergency room services. This item/service falls within the 
Emergency 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 emergency room 
services on June 29, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physical therapy visit provided on July 08, 2022. 
 
You asked the Plan to pay for a physical therapy visit. You say that the patient gave you the wrong plan 
information, so you did not get authorization. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s).there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, we 
decided that the Plan does not have to pay for a physical therapy visit provided on July 08, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on April 6, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you are only required to pay a $30 
copayment for the specialist visit and should not be charged another $100 separately per the 2022 Evidence of 
coverage. The Plan denied your request. The Plan says this cost sharing was charged 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 $0 
copayment for mammography and ultrasounds and a $100 copayment for all other diagnostic radiological 
services.  
 
 You have been asked to pay a $100 copayment for a CT scan. This item/service falls within Outpatient 
Diagnostic Tests 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 a CT scan provided 
on April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140) provided on June 22, 2022 to 
July 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service 05/17/2022. Therefore, 
we decided that the Plan does not have to pay for an oral evaluation (D0140) provided on June 22, 2022 to July 
18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the Eyelea (J0178), injection (67028), and 
provision of supply and material by physician (99070) provided on March 31, 2022, by a foreign provider. 
 
You asked the Plan to reimburse you for the physician services. You say that your coverage has not changed. 
You say that these services have been covered in the past. You also say that this should be paid. The Plan 
denied your request. The Plan says the services in this case were not urgent or emergent. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved 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 physician services have not been met. Specifically, the file does not support 
that the services were urgent or emergent in nature. Therefore, we decided that the Plan does not have to 
reimburse you for the Eyelea (J0178), injection (67028), and provision of supply and material by physician 
(99070) provided on March 31, 2022, by a foreign provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FLEX-WALK SYSTEM (L5981) and advanced ankle 
setting (L5968). 
 
You asked the Plan to pre-approve the prosthesis with advanced foot and ankle features. You say that the items 
are medically necessary. The Plan denied your request. The Plan says these items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 prosthesis with advanced foot and 
ankle features. Our reviewer says that these items are not medically necessary. Our physician reviewer found 
the treating medical provider documentation does not support that the patient is K3 ambulator. Patient is 
utilizing assistive devices to include a manual wheelchair; need for PWC due to some difficulty with self-
propelling longer distances, which does not support the need for a K3 level prosthesis. 
 
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 prosthesis with advanced foot and ankle features have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a FLEX-WALK SYSTEM (L5981) and 
advanced ankle setting (L5968).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the urgent care visit provided on July 29, 
2022. 
 
You asked the Plan to reduce the copayment for the urgent care visit. You say that your copayment should only 
be $35 for an office visit. The Plan denied your request. The Plan says this cost sharing was charged 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 $40 
copayment for urgently needed services. 
 
You have been asked to pay a $40 copayment for the urgent care visit. This item/service falls within the 
urgently needed 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 reduce the copayment for the urgent 
care visit provided on July 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Private Duty Nursing (PDN) services (S9124), provided 
on April 4, 0221, through August 22, 2021. 
 
You asked the Plan to pay for the PDN services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says there is no documentation to verify the caregivers are eligible for 
reimbursement by Medicare or notes for the dates of service signed by the caregivers demonstrating the skilled 
services being performed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the PDN services have been met. there 
is no documentation to verify the caregivers are eligible for reimbursement by Medicare or notes for the dates 
of service signed by the caregivers demonstrating the skilled services being performed.. Therefore, we decided 
that the Plan does not have to pay for the Private Duty Nursing (PDN) services (S9124), provided on April 4, 
0221, through August 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 9, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a claim for the dental services was not filed until July 27, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for dental services provided on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on August 19, 2022. 
 
You asked the Plan to pay for the physician services. You say that the patient was in a nursing home and no 
other provider was allowed into the facility during the COVID-19 pandemic. The Plan denied your request. 
The Plan says that unauthorized, out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the physician services 
provided on August 19, 2022.