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

We decided that the Plan does not have to pay for injections (J3490, Q9966, J1030) provided on March 9, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for injections. You say that this is supported in the records. The Plan denied your 
request. The Plan says this was not 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 injections (J3490, Q9966, J1030) provided on 
March 9, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuropsychological testing provided on April 7, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the neuropsychological testing. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
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 
neuropsychological testing provided on April 7, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for determination of refractive state (92015) provided June 17, 
2021. 
 
You asked the Plan to pay for the vision services. You say that this test was one of many done on your eye in 
preparation for cataract surgery and it was mandatory in order to proceed. Since cataract surgery is covered 
100%, it doesn't make sense for any required tests to be denied. The Plan denied your request. The Plan says 
eye refractions are only covered when performed by a participating provider and performed as part of a routine 
eye exam. 
 
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 performed as part of a routine eye exam. 
 
We looked at the file and the Plan's rules. Eye refraction services are covered when performed during a routine 
eye exam. 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 determination of refractive state 
(92015) provided June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays 
(D0274), prophylaxis (D1110), topical application of fluoride varnish (D1206), and simple extractions (D7140) 
provided from March 23, 2021, to June 15, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, bitewing x-rays, prophylaxis, topical 
application of fluoride varnish, and simple extractions. You say that you were unaware that the treating 
provider was OON, but you were also not provided with a list of in-network providers by the Plan. The Plan 
denied your request. The Plan says there is no coverage when services are rendered by an OON provider. The 
Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider 
eligibility. 
 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), prophylaxis (D1110), topical 
application of fluoride varnish (D1206), and simple extractions (D7140) provided from March 23, 2021, to 
June 15, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on May 5, 2021 and 
May 13, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit.
 
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 outpatient hospital services provided on May 
5, 2021 and May 13, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Freestyle Libre sensors (K0553) provided on June 13, 2021, 
by an out-of-network provider. 
 
You asked the Plan to pay for Freestyle Libre sensors. You say that the items at issue are a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 Freestyle Libre sensors (K0553) provided on June 
13, 2021, by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry services 
(93229). 
 
You asked the Plan to pre-approve external mobile cardiovascular telemetry services. You say that the service 
at issue is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that real-time outpatient cardiac telemetry is considered 
medically unnecessary if other testing could be expected to provide the data/information needed for the 
diagnosis and/or treatment of the patient's condition/symptoms. 
 
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 external mobile cardiovascular 
telemetry services. Our reviewer says that the criteria are not met for coverage of the service at issue. Our 
physician reviewer found the records show no documentation of any other cardiac evaluations 
(electrocardiogram, echocardiogram) which might put him at risk for rhythm disturbances. There is no family 
history of arrhythmias or sudden death recorded either, making the possibility of an arrhythmic cause low. The 
index of suspicion of arrhythmic origin does not appear to be high in this situation, there has been no prior 
evaluation for rhythm disturbances and the notes report 4-6 seizure episodes per day. Therefore, prolonged real 
time mobile cardiac outpatient telemetry monitoring as an initial test would not meet the applicable LCD 
coverage criteria at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of external mobile cardiovascular telemetry services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry services 
(93229).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit for a preventive service at an 
in-network Specialty Physician's office provided on July 8, 2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that the visit was for a pap smear which 
is covered in full by your insurance. The Plan denied your request. The Plan says you are liable for the 
copayment. The medical records confirmed that the claim was submitted correctly since a medical decision was 
made regarding the diagnosis of atrophic vaginitis during the visit in addition to the covered exam. 
 
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 for Physician/Practitioner Services, Including Doctor's Office Visits provided in a Specialty 
Physician's office.  
You have been asked to pay a $10 copayment for an office visit with a specialty physician. An office visit in a 
Specialty Physician's office falls within the Physician/Practitioner Services, Including Doctor's 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 copayment for an office visit for a preventive 
service at an in-network Specialty Physician's office provided on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 10, 2021. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit and 
you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct 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 specialist visits.  
 
You had a follow-up visit with a specialist on June 10, 2021. Follow-up visits are subject to cost-sharing 
charges. Therefore, you are responsible to pay the $45 copayment.  
 
You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's 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 copayment for a specialist visit provided on June 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the computed tomography (CT) scan of the heart 
(75571). 
 
You asked the Plan to pre-approve the CT scan of the heart. You say that this request is medically reasonable 
and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 CT scan of the heart. Our reviewer 
says that the requested imaging service is not medically reasonable and necessary. Our physician reviewer 
found the review indicates that you are an 84-year-old male with a history of prostate cancer, hypertension, 
hypersensitivity lung disease, hypothyroidism, vitamin D deficiency and degenerative joint disease. At issue is 
the request for CT scan of the heart (75571). The review indicates that you are requesting calcium imaging of 
the heart. The most common indication for cardiac computed tomography is the anatomic evaluation of the 
coronary arteries for the presence of coronary artery disease. There is no specific clinical rationale for the 
requested CT scan. 

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 CT scan of the heart have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the computed tomography (CT) scan of the heart (75571).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion referral to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a second opinion referral. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says they have in-network providers available to provide the 
care you require. 
 
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 
a second opinion referral to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a cervical collar (L0174) provided on January 19, 2021, by 
an out-of-network provider. 
 
You asked the Plan to pay for a cervical collar. You say that the item at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 cervical collar (L0174) provided on January 19, 
2021, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on June 3, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for drug testing. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-
of-network with the Plan and the ordering physician was also out-of-network with the Plan.  
 
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 provided on June 3, 2021 by an out-
of-network (OON) provider.
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 records provided support the need for care in an 
IRF. You say that you need to regain maximum function as you are not able to move or do anything for 
yourself in a safe manner. The Plan denied your request. The Plan says the enrollee's condition does not meet 
the Medicare guidelines for coverage of IRF care. The Plan says that the enrollee can safely receive the 
services needed in other settings. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for a urinary tract infection and hyponatremia. The enrollee's medical problems are stable. There 
are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the documentation does support a need for physical and/or occupational therapy, there is no documented 
need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related 
group (DRG) code 871. 
 
You asked the Plan to pay for the inpatient hospital services billed with DRG 871. You say that the correct 
DRG is 871. The Plan denied your request. The Plan says DRG 871 is not supported as the diagnosis of Sepsis 
due to Escherichia coli. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, A41.51, defined as Sepsis 
due to Escherichia coli (E. coli). We asked our physician reviewer to carefully review the case file and apply 
the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient 
hospital services billed with DRG 871. Our reviewer says that the submitted DRG is not supported. Our 
physician reviewer found there was no clinical or laboratory evidence of sepsis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services billed with diagnosis related group (DRG) code 871.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an extracranial bilateral study (93880) 
rendered on August 11, 2021.  
You asked the Plan to waive the coinsurance for an extracranial bilateral study. You say that you believe you 
should not have any responsibility for the claims. The Plan denied your request. The Plan says you were 
charged the correct coinsurance 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 20% 
coinsurance for Outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $53.21 in coinsurance, which is 20% of the allowed amount for extracranial 
bilateral study ($266.03 allowed amount x 20% coinsurance = $53.21). Extracranial bilateral studies fall within 
the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for an extracranial bilateral study (93880) rendered on August 11, 2021.