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

 
We decided that the Plan does not have to waive the copayment for vision services on March 22, 2022. 
 
You asked the Plan to waive the copayment for vision services. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $35 
copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye, including an annual 
glaucoma screening for members at high risk. Covered services include outpatient physician services for the 
diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular 
degeneration. Original Medicare doesnt cover routine eye exams (eye refractions) for eyeglasses/contacts. 
 
 
 
 You have been asked to pay a $35 copayment for vision services. Vision services fall within the Vision 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 vision services on March 22, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a qualified nonphysician health care professional online 
digital assessment provided on May 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a qualified nonphysician health care professional online digital assessment. You 
say that this provider does not file with insurance companies. The Plan denied your request. The Plan says this 
provider is not a Plan provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
   
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a qualified nonphysician health care professional 
online digital assessment provided on May 5, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on January 12, 2022 to June 3, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic 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 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 chiropractic services provided on January 12, 
2022 to June 3, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on March 31, 2022. 
 
You asked the Plan to pay for code 83789. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the Mass spectrometry and tandem mass spectrometry (83789) provided on March 31, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular reeducation (97112) provided on March 
4, 2021. 
 
You asked the Plan to pay for the outpatient physical therapy. You say that the claim was immediately 
submitted to the plan upon receipt of the requisite information. The Plan denied your request. The Plan says the 
claim was not filed within the 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the outpatient physical therapy was not filed until May 27, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the neuromuscular reeducation (97112) provided on March 4, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional therapy is medical necessary. The 
Plan denied your request. The Plan says that the remaining six physical therapy visits are not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee should be able to safely transition to a home exercise 
program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve six physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on January 28, 2022, 
and March 11, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you thought you would only have a 
$40 copayment and did not realize you would have to pay the $366.30 for the rest of the services. You say that 
you have limited income and did not get a bill for this visit. The Plan denied your request. The Plan says the 
coinsurance 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 20% 
coinsurance for Medicare Part B non-chemotherapy prescription drugs.  
 
 
  You have been asked to pay $366.30 per injection, which is 20% of the allowed amount for an injection 
($1,831.49 allowed per injection x 20% = $366.30). An 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 waive the coinsurance for an injection provided on 
January 28, 2022, and March 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), electronic connection 
(E2311), expandable controller harness (E2313), a power seat elevation feature (E2300) and bag hook (K0108). 
 
You asked the Plan to pre-approve an expandable controller, electronic connection, expandable controller 
harness, a power seat elevation feature and bag hook.. You say that these items are medically necessary. The 
Plan denied your request. The Plan says that there is not a medical need to control these power options/features 
through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that a power seat elevation feature is non-covered because it is 
not primarily medical in nature. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose.  
 
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 expandable controller, electronic 
connection and expandable controller harness. Our reviewer says that an expandable controller, electronic 
connection and expandable controller harness are not considered medically reasonable and necessary in this 
case. You are independent with eating, dressing and grooming thus indicating you have adequate upper 
extremity strength and function to operate the wheelchair's power options with their own switches. Our 
physician reviewer found that your condition does not meet criteria for coverage of an expandable controller, 
electronic connection and expandable controller harness. 
 
We looked at this physician's review, the file, and Medicare rules. The bag hook at issue in this appeal does not 
serve a purpose that is primarily medical in nature. The bag hook is available to the general public and would 
be helpful even to those who are not sick or injured. Based on this information, we decided that Medicare rules 
for coverage of an expandable controller, electronic connection, expandable controller harness, a power seat 
elevation feature and bag hook. have not been met. Therefore, we decided that the Plan does not have to pre-
approve an expandable controller (E2377), electronic connection (E2311), expandable controller harness 
(E2313), a power seat elevation feature (E2300) and bag hook (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on April 29, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says there was no documented contact with the attending/primary care 
physician.  
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
provided on April 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 87798, 87641, 88305, and 
88312 provided on October 14, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
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 codes 87798, 87641, 88305, and 88312 are not supported in the medical record. Specifically, 
the documentation does not include medical records from the ordering provider or laboratory results. This 
means it cannot be determined who officially ordered the laboratory testing. This means that the necessity for 
the services rendered is not supported. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded 87798, 87641, 88305, and 88312 provided on October 14, 2021.
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 patient meets full criteria for an inpatient 
rehabilitation stay. You also say that the lack of intensity of therapy at a skilled level of rehabilitation will also 
prolong the member's recovery and put him at increased risk for complications such as recurrent pneumonia, 
skin breakdown, and depression. The Plan denied your request. The Plan says an intensive rehabilitation 
program is not medically necessary. 
 
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 member does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. Our physician 
reviewer also found that there is no indication that the member would require skilled rehabilitation in an IRF, 
or participation in rehabilitation services 15 hours a week, under the supervision of a physician with at least 
three visits weekly to regain or maintain her functional status. Our physician reviewer also found that the 
member can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 waive the copayment for an inpatient hospital stay provided from 
January 22, 2022, to January 25, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you have a bill for $720 
with a remaining balance of $500. You say that you do not want to pay the remaining balance because you 
thought it was an awful experience due to not receiving a private room, as promised. 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 a $240 
copayment per day for days 1-5 per admission for Medicare-covered inpatient hospital stays.  
 
 
  You have been asked to pay $720 for an inpatient hospital stay ($240 x 3 days = $720). You are not charged a 
copayment for the day of discharge. An inpatient hospital stay falls within the Inpatient Hospital 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 an inpatient hospital stay provided from 
January 22, 2022, to January 25, 2022.  
 
Your complaint about not being able to receive a private room is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of benign odontogenic cyst or tumor - lesion 
diameter up to 1.25 cm (D7450), therapeutic parenteral drug, single administration (D9610), and alveoloplasty 
in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7311). 
 
You asked the Plan to pre-approve removal of benign odontogenic cyst or tumor, therapeutic parenteral drug, 
and alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces. You say that you are in 
agonizing pain, and these services are medically necessary. The Plan denied your request. The Plan says these 
services are not covered under your benefits.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm (D7450), therapeutic parenteral 
drug, single administration (D9610), and alveoloplasty in conjunction with extractions - one to three teeth or 
tooth spaces, per quadrant (D7311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided June 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware of the frequency limit. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 11, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or 
established patient (D0150) provided June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-ray (D0270) provided May 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that this x-ray was necessary to diagnose your dental 
issue. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 26, 2022. 
Therefore, we decided that the Plan does not have to pay for the bitewing x-ray (D0270) provided May 11, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 19, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that the sales agent enrolled you with the wrong primary 
care provider. 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 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 laboratory services provided on October 19, 
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 an unspecified adjunctive procedure (D9999) provided on 
March 18, 2021, and periodontal scaling and root planing in all four quadrants (D4342) provided on April 14, 
2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says that the provider has opted out of Medicare and is not eligible for 
payment. 
 The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an 
unspecified adjunctive procedure (D9999) provided on March 18, 2021, and periodontal scaling and root 
planing in all four quadrants (D4342) provided on April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for prophylaxis (D1110) provided on May 11, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the coverage booklet is misleading. 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 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 prophylaxis (D1110) provided on May 11, 
2022.