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

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99326) provided on July 23, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that since the member was in a nursing 
facility, the doctor was not responsible to get authorization. You also say that the nursing home is responsible 
to obtain prior authorization for their patients, which should cover medical treatments by the provider. The Plan 
denied your request. The Plan says this provider is out-of-network with the Plan, and authorization was not 
obtained prior to the services being rendered. 
 
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 domiciliary or rest home visit (99326) provided 
on July 23, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision of hyperplastic tissue (D7970) provided on 
November 1, 2021. 
 
You asked the Plan to pay for the dental service. You say that your denture was not fitting properly. You say 
that this service was necessary as a result. You say that it is your understanding that medically necessary dental 
services are covered. You also say that this should be reconsidered as a medical claim. The Plan denied your 
request. The Plan says this service is dental in nature. The Plan also says that excision of hyperplastic tissue is 
not a covered service. 
 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 excision of hyperplastic tissue is 
not among those covered under this benefit. Additionally, the services you are asking the Plan to pay for 
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. The record shows that the 
service you received is solely to prepare for better fitting dentures/ replacement of teeth. Therefore, we decided 
that the Plan does not have to pay for the excision of hyperplastic tissue (D7970) provided on November 1, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on January 25, 2021. 
 
You asked the Plan to pay for the telehealth visit. The Plan denied your request. The Plan says the member is 
covered for physician/practitioner services, including doctors office visits. The member has the option of 
getting these services through an in-person visit or by telehealth. If the member chooses to get one of these 
services by telehealth, the member must use a network provider who offers the service by telehealth. 
 
The Plan contract says the member must use a network provider who offers the service by telehealth. 
 
We looked at the file and the Plans rules. The file shows that the provider is not a network provider. Based on 
this information, we decided that Plans rules for coverage of the telehealth visit have not been met. Therefore, 
we decided that the Plan does not have to pay for a telehealth visit provided on January 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a radiologic examination of the knee 
(73562) rendered on November 16, 2021. 
 
You asked the Plan to waive the copayment for a radiologic examination of the knee. You say that you 
received a bill for an x-ray for $70, and you thought the copayment was only $20. You also say that you were 
told the copayment was going to be $20 and not $70. The Plan denied your request. The Plan says you were 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $70 
copayment for Medicare-covered x-rays.  
 
 You have been asked to pay a $70 copayment for a radiologic examination of the knee. A radiologic 
examination of the knee 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 a radiologic examination of the knee (73562) 
rendered on November 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on December 13, 2021. 
 
You asked the Plan to pay for foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on December 
13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits (99212, 99213) provider from 
August 26, 2021, to October 20, 2021. 
 
You asked the Plan to waive the copayment for office visits. You say that you were supposed to have a specific 
test done, but when you went to the provider's office, they did not have the equipment to perform your test,  
however, you received a bill for two cost shares for these dates of service. You also say that for the date of 
service on October 20, 2021, you feel the provider did not do anything, he just took your vitals and weight, but 
did not perform your test. The Plan denied your request. The Plan says you were charged the correct cost 
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment per visit for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay a $40 copayment per visit for two office visits, which totals $80 ($40 x 2 = $80). 
Office visits fall within the physician/practitioner services, including doctor's office visits benefit category. The record shows you were seen during these visits. 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 
office visits (99212, 99213) provider from August 26, 2021, to October 20, 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 enrollee is at high risk for decline 
and further complications. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient acute care. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital with acute respiratory failure and left 
temporal hemorrhage, with mass effect following a fall. The course was complicated by Covid-19 infection, 
bacterial pneumonia, and thrombosis of left transverse and sigmoid sinus. The enrollee appears to be improving 
and should only require short-term additional acute care services that can safely be completed at the current 
facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided from 
September 22, 2021, to September 23, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not agree with 
the $50 copayment and the benefit for emergency room services because you were not aware of the copayment 
when you enrolled with the Plan. The Plan denied your request. The Plan says you were charged the correct 
cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for emergency care worldwide.  
 
 
 
 
 
 You have been asked to pay a $50 copayment for an emergency room visit. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an emergency room visit provided from September 22, 2021, to September 23, 
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 for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that there does not appear to be a stability advantage to transfer to 
a long term acute care facility from an acute care hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where he/she is currently receiving care. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for LTACH services. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiogram provided on December 
9, 2021. 
 
You asked the Plan to waive the copayment for an echocardiogram. You say that you should not have to pay 
the copayment for the echocardiogram. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for an echocardiogram.  
 You have been asked to pay a $250 copayment for an echocardiogram. An echocardiogram 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 echocardiogram provided on December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services (92015, 92004) provided on July 16, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for OON vision care. You say that due to administration changes and a lack of 
communication between your staff and previous billing company, you were unaware that your group was no 
longer participating with this Plan. The Plan denied your request. The Plan says out-of-network care is only 
covered in certain limited circumstances. The services at issue were not urgent/emergent, nor were they pre-
approved. These services could have been provided 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 the vision services (92015, 92004) provided on 
July 16, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient surgery provided on April 21, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient surgery. You say that the authorization was not completed due to 
extenuating circumstances and the services rendered was medically necessary. The Plan denied your request. 
The Plan says the rendering provider is an out-of-network provider and there was no referral from an in-
network provider or an approved authorization. Also, the service rendered was not urgent or 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 an outpatient surgery provided on April 21, 2021, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee prosthesis (L5845, L5848, 
L5856, L5828). 
 
You asked the Plan to pre-approve the microprocessor knee prosthesis. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of knee. 
 
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 microprocessor knee prosthesis. Our 
reviewer says that this type of knee is not medically necessary. Our physician reviewer found the requested 
microprocessor knee exceeds the patient's medical needs. The physician medical progress notes do not support 
that the requested microprocessor knee is required over a mechanical K3 knee. 
 
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 microprocessor knee prosthesis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a microprocessor knee prosthesis (L5845, L5848, L5856, L5828).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the outpatient visits provided on February 
16, 2021, March 2, 2021, March 23, 2021, June 22, 2021, July 27, 2021, and October 26, 2021. 
 
You asked the Plan to waive the copayments for the outpatient visits. You say that there should not be an 
additional copayment for the services provided when you already pay a copayment for the specialist visit. The 
Plan denied your request. The Plan says the proper copayments were applied for the dates of service. 
 
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 all other Medicare-covered outpatient hospital services. The total copayment amount for all the 
dates of service is $60 ($10 copayment x 6 dates of service). 
 You have been asked to pay a $60 copayment for the outpatient visits. The outpatient visits falls within 
Outpatient hospital services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the 
outpatient visits provided on February 16, 2021, March 2, 2021, March 23, 2021, June 22, 2021, July 27, 2021, 
and October 26, 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 enrollee cannot be adequately care 
for in her current condition at a skilled nursing facility. The Plan denied your request. The Plan says the 
LTACH would add no additional services. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital with pneumonia, acute hypoxic 
respiratory failure, pleural effusion, and sepsis. She was treated with antibiotics, intubation, diuresis, and 
sedation. Recent notes describe the enrollee as only recently starting trach collar trials, acute kidney injury 
resolved, hemodynamically stable, and no active bleeding. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Therefore, transfer to 
LTACH is not medically necessary as it would not be clinically advantageous. 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80050) provided on July 22, 2021. 
 
You asked the Plan to pay for the general health panel. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
(80050) provided on July 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an intravenous infusion, hydration (96360) 
provided on October 15, 2021. 
 
You asked the Plan to waive the copayment for an intravenous infusion, hydration. You say that you are 
dissatisfied that a test you have been doing for several years is not covered enough by your insurance. You also 
say that a hydration service is done in one facility and the test is done in another facility, and you would like 
reconsideration that the Plan include the preparation in the actual diagnostic test done. The Plan denied your 
request. The Plan says you were charged the cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $310 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay $205.49, which is less than the $310 copayment for an intravenous infusion, 
hydration. An intravenous infusion, hydration falls within the outpatient surgery and other medical services 
provided at hospital outpatient facilities and ambulatory surgical centers 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 intravenous infusion, hydration (96360) provided on October 15, 
2021.