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

 
We decided that the Plan does not have to pay for procedure code 70470 billed for date of service June 14, 
2022. 
 
You asked the Plan to pay for procedure code 70470. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 70470 is bundled into payment for code 0042T.  
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 70470 
is a column II code to column I code 0042T. 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 70470 billed for date of service June 14, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral, periapical first film (D0220) and intraoral, 
periapical each additional film (D0230) provided June 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are a diabetic and your dental x-rays were 
not covered. The Plan denied your request. The Plan says these services are not listed as covered under the Plan 
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. The health Plan contract says that any services not listed are not 
covered. Therefore, we decided that the Plan does not have to pay for intraoral, periapical first film (D0220) 
and intraoral, periapical each additional film (D0230) provided June 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs received on August 4, 2022.

You asked the Plan to pay for the drugs. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered by Medicare based on statutory exclusion.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received on August 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth and office visits provided on May 26, 2022, and 
June 13, 2022, by an OON provider. 
 
You asked the Plan to pay for the telehealth and office visits. The Plan denied your request. The Plan says the 
out-of-network services were 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 a telehealth and office visits provided on May 26, 
2022, and June 13, 2022, by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on April 20, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy services. You say that this should be covered, the patient needed 
these services. The Plan denied your request. The Plan says there was no preauthorization by a primary care 
provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 physical therapy services provided on April 20, 
2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 12, 2022, and 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from November 12, 2022, and forward. You say 
that the requested inpatient psychiatric care from November 12, 2022, and forward is medically necessary. The 
Plan denied your request. The Plan says the requested inpatient psychiatric care from November 12, 2022, and 
forward is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 inpatient psychiatric care from 
November 12, 2022, and forward. Our reviewer says that the requested inpatient psychiatric care from 
November 12, 2022, and forward is not medically necessary. Our physician reviewer found this enrollee did 
not appear to require inpatient mental health treatment as she was not a danger to herself or others and was 
cooperative with care without any aggressive behaviors. It did not appear that active treatment was taking 
place. It did not appear that the services were reasonably expected to improve the enrollees condition or for the 
purpose of diagnosis. I am unable to find an individualized treatment plan though the entire record is not 
present. It did appear that the records were supervised and evaluated by a physician. Based upon review of the 
records provided the admission of this enrollee does not meet criteria for acute inpatient mental health 
treatment as this enrollee was not shown to be a danger to herself or others, no auditory or visual 
hallucinations. She is noted to be cooperative and compliant with treatment while not showing any aggressive 
behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from November 12, 2022, and forward have not been 
met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from 
November 12, 2022, and forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4209 and A4210 billed for date of service 
October 26, 2021. 
 
You asked the Plan to pay for procedure codes A4209 and A4210. You say that this item was medically 
necessary. The Plan denied your request. The Plan says these billed codes are excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes A4209 and A4210 have a Status Indicator of X on the Physician Fee Schedule. 
This means that procedure codes A4209 and A4210 are statutorily excluded from payment.  Therefore, we decided that the Plan does not have to pay for procedure codes A4209 and A4210 billed for date of service 
October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 29, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on December 29, 2021, by 
an out-of-network (OON) provider.
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 
July 17, 2022, to July 21, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this is the third 
hospitalization in a short span of time, for the same issue. You were only out of the hospital for a week before 
you were inpatient again. The Plan denied your request. The Plan says this cost sharing was charged 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 $345 
copay per day for days 1 through 5 for inpatient hospital care. You were inpatient for 4 days, resulting in a 
$1380 total copayment ($345 x 4 days = $1,380). 
 
You have been asked to pay a $1,380 copay for an inpatient hospital stay. This item/service 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 July 17, 2022, to July 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88331) provided on June 7, 2022. 
 
You asked the Plan to pay for the pathology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed is not separately payable. 
 
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 88331 is not supported in the medical record. Specifically, the pathology service is 
included in the primary procedure (17313). Based on this information, we decided that Medicare rules for 
coverage of the pathology services have not been met. Therefore, we decided that the Plan does not have to pay 
for pathology services (88331) provided on June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on May 11, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for hospital outpatient clinic visit. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
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 hospital outpatient clinic visit provided on May 
11, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on March 9, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the rendering provider was the only facility where 
the enrollee would qualify for admission. The Plan denied your request. The Plan says the services were 
received from an out-of-network provider without a prior authorization. The Plan also says that the services 
were neither urgent nor emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue.  
 
 We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that 
the Plan does not have to pay for lab testing provided on March 9, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac computed tomography for calcium scoring. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the results from this scan will not change the recommendation for the enrollee to be on a 
statin. 
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that coronary calcium 
scoring as a screening test for asymptomatic patients is not covered. Without any records, even a lipid profile, 
the medical necessity of this request cannot be established. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a cardiac computed tomography for calcium scoring.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from December 10, 2021, 
to January 8, 2022. 
 
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 not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that HHAs must send a Notice of Admission (NOA) to 
Medicare. 
 
We looked at the file and Medicare rules. The file shows that a valid NOA was not submitted for the claim. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services rendered from December 
10, 2021, to January 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for upgraded lenses (V2744, V2781, V2782) provided on July 
14, 2022. 
 
You asked the Plan to pay for the upgraded lenses. You say that the lenses were medically necessary. The Plan 
denied your request. The Plan says upgraded lenses are not a covered benefit. 
 
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 Standard eyeglass lenses including coverage of single, bifocal, or trifocal lens every 
year. Lens upgrades including polycarbonate, progressive, transition lens, tints, and scratch resistant coating are 
not covered. 
 
We looked at the file and the Plan's rules. Upgraded lenses are not a covered benefit. Based on this information, 
we decided that the Plan's rules for coverage of the upgraded lenses have not been met. Therefore, we decided 
that the Plan does not have to pay for upgraded lenses (V2744, V2781, V2782) provided on July 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on April 19, 2022, to April 
27, 2022. 
 
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 not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that HHAs must send a Notice of Admission (NOA) to 
Medicare by mail. 
 
We looked at the file and Medicare rules. The file shows that a valid NOA was not submitted with the claims. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services rendered on April 19, 
2022, to April 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on June 28, 2022. 
 
You asked the Plan to waive the copayment for the x-ray. You say that the smart summary says the service as 
approved but not paid by the Plan.  The Plan denied your request. The Plan says this cost sharing was charged 
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 $95 
copayment for diagnostic procedures and tests at an in-network outpatient hospital.  
 
You have been asked to pay a total of $83.94, which is less than the standard $95 copayment for the x-ray. This 
item/service falls 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 copayment for an x-ray provided on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on May 6, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service was medically 
necessary. The Plan denied your request. The Plan says services received out-of-network are not covered. 
 
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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service 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 (99202) provided on May 6, 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 collagen dressing supplies (A6021) provided on July 6, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the collagen dressing supplies. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items 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 collagen dressing supplies (A6021) provided on 
July 6, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transcatheter insertion or replacement of permanent 
leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, 
ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when 
performed (33274). 
 
You asked the Plan to pre-approve the surgical procedure. You say that please find attached the relevant 
medical records to support the procedure request. The Plan denied your request. The Plan says under Medicare guidelines, this request is not medically necessary because the records do not show that the enrollee is in a 
CMS approved CED study. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. In order for the requested services to be covered, clinical notes need 
to show that the enrollee is currently or is going to be enrolled and participating in a CMS approved CED 
study. The records do not show that the enrollee is enrolled in a CMS approved CED study. Based on this 
information, we decided that Medicare rules for coverage of the surgical procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the transcatheter insertion or replacement of 
permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous 
ultrasound, ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), 
when performed (33274).