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

We decided that the Plan does not have to pay for the office visit and injection services provided on June 28,
2021, by an OON provider.
You asked the Plan to pay for the OON services. You say that the attached notes support the need for services.
The Plan denied your request. The Plan says 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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The file shows that the enrollee was seen for knee pain. The provider in this case is not a network provider with
the Plan. The Plan had network providers available who could have provided the services at issue in this
appeal. 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 the office visit and
injection services provided on June 28, 2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Superion Interspinous Spacer may be implanted at one or two adjacent 
lumbar levels in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5. 
The Food and Drug Administration states that the requested procedure is contraindicated in individuals with 
morbid obesity defined as a body mass index (BMI) greater than 40. In this case, the enrollee indicates that the 
enrollee has chronic low back pain and lumbar spinal stenosis with claudication. The record indicates that the 
enrollee has a body mass index of 41.1. The elements of the coverage criteria are not satisfied. The requested 
service cannot be 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression devices (E0673, E0675) 
provided on April 6, 2021. 
 
You asked the Plan to pay for intermittent limb compression devices. You say that the requested items were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices 
are not covered by Medicare for prevention of deep vein thrombosis. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
devices (E0673, E0675) provided on April 6, 2021
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health care supervision provided on February 9, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health care supervision. The Plan denied your request. The Plan says 
the services were performed by a non-participating provider and were not authorized by 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 the home health care supervision provided on 
February 9, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the computed tomography (CT) guidance for placement of radiation
therapy fields (77014) provided on March 29, 2021, through March 31, 2021.
You asked the Plan to pay for the CT services. You say that you would like this claim reprocessed for medical
necessity. The Plan denied your request. The Plan says that the Plan says that the code 77014 is considered
incidental when performed within 60 days before or after the date of service 77301 was performed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 77014 is supported in the medical record. Specifically, there is no Medicare guidance to
indicate that CPT code 77014 is considered incidental when performed within 60 days before or after the date
of service when CPT code 77301 was performed. It is the burden of the Health Plan to substantiate their denial
with evidence. The Plan has not provided any evidence as to why CPT code 77014 is not separately
reimbursable. This denial has not been substantiated so we must find in your favor. Based on this information,
we decided that Medicare rules for coverage of the CT guidance have been met. Therefore, we decided that the
Plan has to pay for the computed tomography (CT) guidance for placement of radiation therapy fields (77014)
provided on March 29, 2021, through March 31, 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: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the additional intraoral periapical x-ray (D0230). We decided that the 
Plan does not have to pay for the comprehensive oral evaluation (D0150).  
 
You asked the Plan to pay for the comprehensive oral evaluation and additional intraoral periapical x-ray. You 
say that you were billed $263.00 and believe that is a lot for a cleaning. The Plan says that you have exhausted 
your benefit coverage for these services. 
 
We decided that the Plan has to pay for the additional intraoral periapical x-ray (D0230).  
 
The Plan follows Medicare rules. Medicare rules say that the health plan must provide you with a clear and 
accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under 
your plan contract including applicable conditions and limitations and any other conditions associated with the 
use or receipt of the benefits.  
 
The record shows that you received an additional intraoral periapical x-ray on April 15, 2021. The 2021 
Evidence of Coverage states that first intraoral periapical x-ray and each additional intraoral x-ray are each 
limited to once per year. The record shows that you received a complete series of intraoral x-rays on February 
1, 2021, which did not exhaust your first or additional intraoral x-rays benefits. The contract does not clearly 
state that you are limited to either one complete series of intraoral x-rays, one first intraoral periapical x-ray, or 
one additional intraoral periapical x-ray per year. You reasonably believed the additional intraoral periapical x-
ray would be covered because it is shown that it is covered once per year in the 2021 EOC. Therefore, we 
decided that the Plan has to pay for the additional intraoral periapical x-ray (D0230).  
 
We also decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150). 
 
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, comprehensive oral evaluation is 
limited to 1 per 3 years. The record shows that you received a comprehensive oral evaluation (D0150) on 
February 1, 2021 and your comprehensive oral evaluation benefit has been exhausted. Therefore, we decided 
that the Plan does not have to pay for the comprehensive oral evaluation (D0150). 
 
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 pre-approve a porcelain crown (D2750) and periodontal scaling and 
root planing (D4341). 
 
You asked the Plan to pre-approve a porcelain crown and periodontal scaling and root planing. You say that the 
requested services are a necessity for your care. The Plan denied your request. The Plan says medical necessity 
rules for the requested services have not been met. 
 
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. The Plan covers a porcelain 
crown and periodontal scaling and root planing when the services are medically necessary and reasonable.  
 
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 porcelain crown and periodontal 
scaling and root planing. Our reviewer says that the requested services are not medically reasonable and 
necessary in this case. Our physician reviewer found that the documentation provided was not sufficient to 
make a determination of medical necessity for the crown and for the periodontal scaling and root planing. The 
radiographs provided were not of diagnostic quality. The documentation provided did not meet the criteria for 
coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a porcelain crown and periodontal scaling and root planing have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a porcelain crown (D2750) and periodontal 
scaling and root planing (D4341).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdomen x-ray provided on June 11, 2021, by an OON 
provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 abdomen x-ray provided on June 11, 2021, by 
an OON provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health care services provided from May 8, 2020, to 
June 6, 2020. 
 
You asked the Plan to pay for the home health services. You say that an employee made a mistake. You also 
say that a correction needs to be made. The Plan denied your request. The Plan says the claim was processed 
correctly. The Plan also says that medical records were not received. 

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 Medicare rules for 
coverage of the home health services have not been met. Specifically, there were no records provided to 
support the services that were billed. The record shows that the Plan requested this documentation, but none 
was received. Therefore, we decided that the Plan does not have to pay for the home health care services 
provided from May 8, 2020, to June 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on July 2, 2021. 

You asked the Plan to waive the copayment for the office visit. You say that your primary care doctor sent you 
to this provider and did not inform you they were a specialist. You say that you weren't informed of the 
copayment and you shouldn't have to pay the claim. The Plan denied your request. The Plan says the 
copayment applied 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 $35 
copayment for provider and professional services from an in-network specialist.  
 
You have been asked to pay a $35 copayment for the office visit. The office visit falls within the 
"Physician/Practitioner services, including doctor's office visits" benefit category. This provider is an 
optometrist which is considered a specialist. 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 the office 
visit provided on July 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep gum and root cleaning (D4341). 
 
You asked the Plan to pre-approve the services. You say that you are a type 1 diabetic, and will lose your teeth 
without this service. The Plan denied your request. The Plan says you did not elect one of the optional 
supplemental benefit packages. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve deep gum and root 
cleaning (D4341).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas therapy and multivitamin injections billed with 
CPT codes J3490, J7999, G0283 and 97750 and provided on March 16, 2021. 
 
You asked the Plan to pay for the Sanexas therapy and multivitamin injections. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the sanexas 
therapy and vitamin injections are not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Sanexas therapy and multivitamin injections have not been met. Specifically, review of the file 
and publicly available records, we find that the physical therapy services at issue in this case were rendered by 
an NP/PA who is not licensed to provide physical therapy in the State of Oklahoma. Additionally, the record 
does not contain documentation of the dosage and type of drug administered in each injection, which is 
required by Medicare for these services to be reimbursed. Therefore, we decided that the Plan does not have to 
pay for the Sanexas therapy and multivitamin injections billed with CPT codes J3490, J7999, G0283 and 97750 
and provided on March 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the coinsurance for the inpatient admission and
services provided from February 9, 2021, to February 11, 2021.
You asked the Plan to waive or reduce the coinsurance for the inpatient care. You say that you cannot be
balance billed and you were told that your bill could be reduced. The Plan denied your request. The Plan says
you are responsible for 20% coinsurance for inpatient hospital care. Your benefits were applied in accordance
with your contract.
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 20%
coinsurance for inpatient hospital care.
You have been asked to pay $773 for the inpatient care. The total amount billed by the provider was
$18,010.56. The Plan's allowed fee for the care received is $7,869.05. You are responsible for 20%
coinsurance of the Plan's allowed amount ($7,869.05 x 20% = $1,573.81). Based on the documentation
provided, it appears that you met your out-of-pocket maximum for the year when this claim was processed, and
you were charged less than the full copayment for this care because your annual maximum was met. 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 or reduce the coinsurance for the inpatient admission and services provided
from February 9, 2021, to February 11, 2021
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care facility. There are 
no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the health plan. 
 
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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 that there is not a reasonable expectation that you 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (EGD) 
and colonoscopy procedures you had at an outpatient hospital facility on August 25, 2020. 
 
You asked the Plan to waive the copayment for the EGD and colonoscopy. You say that you were told that you 
had a $0 copayment for colonoscopies but you have now received a bill. The Plan denied your request. The 
Plan says you were charged this copayment correctly.  The Plan says that you were not assessed a copayment 
for the colonoscopy.  The Plan says that you were charged this copayment for the EGD procedure. 
 
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 $275 
copayment for outpatient surgery and services at an outpatient hospital facility.  
 
You have been asked to pay a $275 copayment for the EGD. The EGD falls within the outpatient surgery and 
services at an outpatient hospital facility 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 the esophagogastroduodenoscopy (EGD) and colonoscopy procedures you had at an outpatient hospital 
facility on August 25, 2020.