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

 
We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve dialysis services to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria 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 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 
dialysis services to be provided by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on February 11, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that you were only there for a short time and 
didn't see anyone so this should be covered. 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 $120 
copayment for each Medicare-covered emergency room visit.  
 
You have been asked to pay $120 copayment for ER visit. ER visits fall 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 ER visit provided on February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic treatment provided on January 17, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a chiropractic treatment. You say that you were uninformed of network issues at 
the time of Plan enroll date. The Plan denied your request. The Plan says services from non-participating 
providers are not covered under your plan unless they are authorized by the Plan before the services are 
provided. 
 
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 a chiropractic treatment provided on January 17, 
2022, 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 ankle foot orthosis (L1971) and heel stabilizer (L3170) 
provided on February 24, 2022. 
 
You asked the Plan to pay for the medical equipment. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. In this case, the medical records do not indicate that the ordering provider discussed the medical 
need for the requested equipment with the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the ankle foot orthosis (L1971) and heel stabilizer (L3170) provided on February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure provided on July 
6, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the unlisted molecular pathology procedure. You say that you are the only 
provider to provide this service and should be considered in-network. The Plan denied your request. The Plan 
says no 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 did not pre-approve the 
unlisted molecular pathology procedure. We found no exception that would require the Plan to pay for the 
unlisted molecular pathology procedure. The records provided for review do not show that the unlisted 
molecular pathology procedure was urgent or emergent. Therefore, we decided that the Plan does not have to 
pay for the unlisted molecular pathology procedure provided on July 6, 2021, 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 progressive lens (V2781), anti-reflective coating 
(V2750), polycarbonate or equal lens (V2784), and frames (V2020) provided on March 11, 2022. 
 
You asked the Plan to pay for the glasses. You say that you were not aware that the policy was changed from a 
yearly contract to a two-year contract. The Plan denied your request. The Plan says these glasses exceed the 
maximum benefit per period. 
 
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 1 pair of standard lenses and frames every 2 years. 
 
We looked at the file and the Plan's rules. The record shows that the Plan paid for one pair of glasses provided 
on April 27, 2021, and your routine eyewear benefit has been exhausted. Based on this information, we decided 
that the Plan's rules for coverage of the glasses have not been met. Therefore, we decided that the Plan does not 
have to pay for the progressive lens (V2781), anti-reflective coating (V2750), polycarbonate or equal lens 
(V2784), and frames (V2020) provided on March 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for basic life support, emergency transport 
ambulance service and ground mileage provided on February 19, 2022. 
 
You asked the Plan to waive the copayment for basic life support, emergency transport ambulance service and 
ground mileage. You say that you are an elderly person and cannot bear this financial burden. The Plan denied 
your request. The Plan says you were 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 $300 
copayment for each one-way Medicare-covered ground transportation service.  
 
 You have been asked to pay a $300 copayment for basic life support, emergency transport ambulance service 
and ground mileage. Basic life support, emergency transport ambulance service and ground mileage fall within 
the ambulance services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for basic life 
support, emergency transport ambulance service and ground mileage provided on February 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe frames (V2020) and determination of refraction state 
(92015) provided February 2, 2022. 
 
You asked the Plan to pay for the vision services. You say that you paid $760 for your glasses and you demand 
that you be reimbursed. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
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 rendered by an in-network provider. 
 
We looked at the file and the Plan's rules. vision services must be rendered by an in-network provider Based on 
this information, we decided that the Plan's rules for coverage of the vision services have not been met. 
Therefore, we decided that the Plan does not have to pay for deluxe frames (V2020) and determination of 
refraction state (92015) provided February 2, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for mental health visit provided on February 7, 
2022. 
 
You asked the Plan to waive the copayment for mental health visit. You say that you were never seen and never 
had a visit so there should be no charge. 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 $40 
copayment for each Medicare covered visit. 
 
You have been asked to pay $40 copayment for mental health visit. Mental health visits fall within the 
Outpatient Mental Health 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 
mental health visit provided on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the apicoectomy - anterior (D3410) provided 
December 2, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that you feel this should be covered at 50% 
because there were no in-network providers available. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider. 
 
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. 
 
 You have been asked to pay 30% of the Allowable Charge for the apicoectomy, an endodontic service. You 
have also been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the apicoectomy - anterior (D3410) provided 
December 2, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral sacroiliac joint steroid injection. 
 
You asked the Plan to pre-approve a bilateral sacroiliac joint steroid injection. You say that a bilateral 
sacroiliac joint steroid injection is medically necessary. The Plan denied your request. The Plan says bilateral 
sacroiliac joint steroid injections are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a bilateral sacroiliac joint steroid 
injection. Our reviewer says that a bilateral sacroiliac joint steroid injection is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that a trial of conservative therapy such as 
physical therapy or chiropractic treatment is warranted before an interventional procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a bilateral sacroiliac joint steroid injection. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a bilateral sacroiliac joint steroid injection.
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 enrollee is eligible for discharge, and 
it would be best for her to be discharged to another facility so she can get better with the goal being to go 
home. You also say that the enrollee needs more physical therapy and occupational therapy. The Plan denied 
your request. The Plan says criteria for admission to the LTACH have not been met. 
 
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 patient does not require services at the LTACH that are not already available at 
the current facility. Our reviewer found that there are no services at the LTACH that the patient requires that 
are not already available and covered at the current facility. Our physician reviewer also found that transfer to 
the LTACH is not medically necessary as it would not be clinically advantageous. Completion of treatment at 
the current facility is recommended. 
 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit on May 26, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit on May 26, 2021. You say that you 
did not receive this service. The Plan denied your request. The Plan says you must pay a $120 copayment for 
each emergency room visit. 
 
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 $120 
copayment for Emergency Care.  
 
You have been asked to pay a $120 copayment for an emergency room visit on May 26, 2021. An emergency 
room visit falls within the Emergency Care benefit category. Records submitted support you had an emergency 
room visit on May 26, 2021.  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 emergency room visit 
on May 26, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided from February 21, 2022, 
to February 24, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that since you were in observation so long it 
should be waived. 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 $90 
copayment per visit for emergency care.  
 
You have been asked to pay $90 copayment for ER visit. ER visits fall 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 ER visit provided from February 21, 2022, to 
February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medial branch block (MBB). 
 
You asked the Plan to pre-approve an MBB. You say that an MBB is medically necessary. The Plan denied 
your request. The Plan says based on submitted clinicals, the beneficiary does not meet criteria as per LCD 
Facet Joint Interventions for Pain Management L34892 policy, specifically.  The Plan follows Medicare rules. 
 
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 an MBB. Our reviewer says that an 
MBB is not medically reasonable and necessary. Our physician reviewer found there is no need to repeat 
diagnostic MBBs at the same site as successful radiofrequency ablation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MBB have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an MBB.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH is the most appropriate 
setting for the enrollee. The Plan denied your request. The Plan says that the records do not show that the 
ongoing care the enrollee needs can only be given in an inpatient hospital setting. 
 
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. The patient 
appears to be stable and improving and should only require short-term additional acute care services that can be 
safely completed at the current facility until more appropriate for a lower level of care. The patient does not 
require services at the LTACH that are not already available at the current facility. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and drug testing provided on March 24, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and the drug testing. You say that the services were medically 
necessary. You say you believe in treating the enrollee's medical needs first. The Plan denied your request. The 
Plan says no 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 did not pre-approve the 
office visit and the drug testing. We found no exception that would require the Plan to pay for the office visit 
and the drug testing. The records provided for review do not show that the office visit and the drug testing were 
urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit and drug 
testing provided on March 24, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service March 15, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that the records support that this procedure was 
performed. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for 
code 32557. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 71045 is a column II code to column I code 32557. 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 71045 
billed for date of service March 15, 2022.