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

 
We decided that the Plan does not have to pre-approve acupuncture services. 
 
You asked the Plan to pre-approve acupuncture. You say that you were told acupuncture combined with the 
things you are already doing will help with your pain. The Plan denied your request. The Plan says records do 
not show that you have had chronic back pain for 12 weeks or longer with no identifiable causes. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, there is no documentation that you have non-specific 
low back pain that has been present for at least 12 weeks. This treatment for any other condition is non-covered 
by Medicare. Therefore, we decided that the Plan does not have to pre-approve acupuncture services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on January 
26, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you thought this would be 
covered in full and you cannot afford this copayment. The Plan denied your request. The Plan says the 
copayment applied is correct. 
 
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 $250 
copayment each one-way trip.  
 
You have been asked to pay $250 copayment for ambulance transport. Ambulance transport falls 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 transport 
provided on January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consult and travel services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the consult and travel 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 correctly as 
they were non-emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The 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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
consult and travel services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's service provided on February 1, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they 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 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 physician's service provided on February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant (D6010), implant supported fixed upper 
denture (D6114), implant supported fixed lower denture (D6115), implant supported interim fixed lower 
denture (D6118), implant supported interim fixed upper denture (D6119), connecting bar (D6055 x 2), bone 
graft at time of implant placement (D6104), and prefabricated abutment (D6056). 
 
You asked the Plan to pre-approve the dental services. You say that the requested services are necessary for 
your health. The Plan denied your request. The Plan says the requested services are not listed as covered. 
 
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, the requested dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
implant (D6010), implant supported fixed upper denture (D6114), implant supported fixed lower denture 
(D6115), implant supported interim fixed lower denture (D6118), implant supported interim fixed upper 
denture (D6119), connecting bar (D6055 x 2), bone graft at time of implant placement (D6104), and 
prefabricated abutment (D6056).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 6, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on November 
18, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you went for a COVID-19 
test and were told there was no charge. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing 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 $45 
copayment for each urgent care visit.  
 
You have been asked to pay a $45 copayment for the urgent care visit. The urgent care visit 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 waive the copayment for an urgent 
care visit provided on November 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80053, 80061, 81000, 82043, 82306, 82570, 
82607, 82746, 83036, 84439, 84443, 84550, 85025, 86769) provided on June 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (80053, 80061, 81000, 82043, 82306, 82570, 82607, 82746, 
83036, 84439, 84443, 84550, 85025, 86769) provided on June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the orthopedic visit. You say that the services are medically necessary. The 
Plan denied your request. The Plan says there are in-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The 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. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an 
orthopedic visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for home visits provided from January 1, 
2022, to February 28, 2022. 
 
You asked the Plan to waive the copayments for home visits. You say that you should not have these 
copayments. The Plan denied your request. The Plan says the copayments applied were correct. 
 
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 $30 
copayment for each Medicare-covered specialist visit for Physician/Practitioner Services.  
 
You have been asked to pay a $30 copayment for each Medicare-covered specialist home visit (2 visits x $30 = 
$60).  
Home visits fall within the Physician/Practitioner Services, Including Doctors Office Visits 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 copayments for home visits provided from 
January 1, 2022, to February 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to be able to go to an acute rehab 
facility so that he may gain strength to return to his previously functionality which included being completely 
independent. The Plan denied your request. The Plan says the inpatient rehabilitation facility services requested 
do no meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 the enrollee's functional status is at a relatively high level following a prolonged 
hospitalization. He does not have intensive rehabilitation needs. His medical condition is stable. He has no 
medical problem which will inhibit his rehabilitation needs but his dialysis and endurance will limit his 
capacity for intensive rehabilitation and as previously stated his functional status does not warrant intensive 
rehabilitation. There is no indication for frequent physiatry oversight as he does not have complex needs. He 
primarily requires endurance training. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92012) provided on May 16, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that you were concerned about your eye due to a new 
issue you had not experienced before. The Plan denied your request. The Plan says the treating provider is not a 
network provider with the Plan. The Plan also says that these services are not urgent or emergent, nor were they 
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 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 eye exam (92012) provided on May 16, 2022 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the x-ray coded 73110, the lengthening or shortening of flexor or 
extensor tendon coded 25280, the arthrotomy coded 25040, and the fluoroscopy services coded 76000 provided 
on November 2, 2021. 
 
You asked the Plan to pay for the x-ray, the lengthening or shortening of flexor or extensor tendon, the 
arthrotomy, and the fluoroscopy services. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says that the services billed are inclusive to other procedure codes. 
 
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 codes 
73110, 25280, 25040, and 76000 are not column II codes to any of the codes the Plan is stating they are 
inclusive to. 
 
The Plan is stating that code 73110 is considered inclusive to procedure code 25609; however, there is no 
NCCI edit for these specific codes. That means these codes are not inclusive to one another.  
The Plan is stating that code 25280 is considered inclusive to procedure code 25609; however, there is no 
NCCI edit for these specific codes. That means these codes are not inclusive to one another. 
The Plan is stating that code 25040 is considered inclusive to procedure code 25609; however, there is no 
NCCI edit for these specific codes. That means these codes are not inclusive to one another. 
The Plan is stating that code 76000 is considered inclusive to procedure code 25609; however, there is no 
NCCI edit for these specific codes. That means these codes are not inclusive to one another. 
The documentation does not support any other way of these services being inclusive to one another.  
 
 We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the x-ray, the lengthening or shortening of flexor or extensor tendon, the arthrotomy, and the 
fluoroscopy services have been met. Therefore, we decided that the Plan has to pay for the x-ray coded 73110, 
the lengthening or shortening of flexor or extensor tendon coded 25280, the arthrotomy coded 25040, and the 
fluoroscopy services coded 76000 provided on November 2, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services were not urgent or emergent. 
 
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 laboratory services provided on March 2, 2022, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an onabotulinumtoxina injection provided 
on February 1, 2022. 
 
You asked the Plan to reduce the coinsurance for the injection. You say that the previous year you only paid 
$100 for the same service. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay $870.92, which is 20% of the allowed amount for the injection ($4,354.58 allowed 
amount x 20% coinsurance = $870.92). Please note that the Plan has indicated the claim from November was 
processed incorrectly. The 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 reduce the coinsurance for an onabotulinumtoxina injection provided on February 1, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on March 
10, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you never had a copayment 
before, and you shouldn't be charged now. The Plan denied your request. The Plan says the copayment applied 
is correct. 
 
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 $45 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office (as 
permitted under Medicare rules). 
 
 You have been asked to pay $12.65 which is less than the standard $45 copayment for specialist office visit. 
Specialist office visits fall within the Physician/Practitioner Services, Including Doctors Office Visit 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 specialist office visit provided on March 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a back injection provided on February 17, 
2022. 
 
You asked the Plan to waive the copayment for the injection. You say that your doctor did not order the 
procedure. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
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 $475 
copayment for each outpatient hospital facility visit.  You have been asked to pay a $475 copayment for the injection. The injection falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 back injection provided on February 17, 
2022.