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

 
We decided that the Plan does not have to pay for an office visit provided on July 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you went to the provider due to the first on that 
found the study. The Plan denied your request. The Plan says there is no authorization on file for the services 
provided. 
 
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 July 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal tooth 3 
(D2750). 
 
You asked the Plan to pre-approve the dental services. You say that you are in a lot of pain and need this 
service badly. 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 June 5, 2020. Therefore, 
we decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal tooth 3 
(D2750).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, and 88360 billed for date of 
service February 16, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, and 88360. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says these codes are 
included in the facility payment and are not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, and 
88360. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342, and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342, and 88360 billed for date of service February 16, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided on August 18, 2022. 
 
You asked the Plan to pay for the mental health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the mental health 
services provided on August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a practitioner visit provided on August 23, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a practitioner visit. You say that an authorization should be on file for the 
enrollees stay. The Plan denied your request. The Plan says authorization was not obtained prior to the services 
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 practitioner visit provided on August 23, 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 care provided from December 2, 2020, to 
August 31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic care. You say that you should be reimbursed for the services. 
The Plan denied your request. The Plan says the provider is out-of-network and authorization was not obtained 
prior to services being rendered. Network providers were available to render appropriate care. 
 
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 care provided from December 2, 
2020, to August 31, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for continuous positive airway pressure 
equipment and supplies provided on August 23, 2022. 
 
You asked the Plan to waive the coinsurance for continuous positive airway pressure equipment and supplies. 
You say that you cannot afford to pay this. 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for continuous positive airway pressure equipment and supplies. 
This item/service falls within the durable medical equipment (DME) and related supplies benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for continuous positive airway pressure equipment and 
supplies provided on August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist visit provided on August 11, 
2022. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you are disputing the share cost. 
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 $32 
copayment for physician/practitioner services, including doctors office visits.  
 
You have been asked to pay $32 copayment for specialist visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for specialist visit provided on August 11, 2022.  
 Your complaint about you never had an office visit or any communication with a kidney specialist are not 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 pay more for dental services provided on August 18, 2022 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says your $2,000 dental benefit maximum 
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 August 18, 2022. 
Therefore, we decided that the Plan does not have to pay more for dental services provided on August 18, 2022
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from January 10, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from January 10, 2023, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
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 January 
10, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of January 10, 2023, forward. Our physician reviewer found the 
enrollee did not require inpatient mental health treatment beyond January 10, 2023, as she was not a danger to 
herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollees condition or for the 
purpose of diagnosis. 
 
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 January 10, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from January 10, 
2023, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve elevating leg rests and an electronic connection. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee experiences spasticity and 
severe muscle cramping. The Plan denied your request. The Plan says coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has a neurologic disorder with functional deficits. The documentation does not 
support the need for elevating leg rests. The requested electronic connection is not medically necessary as the 
enrollee does have use of the upper extremity and can operate and control the power options using the switches 
that are included in the basic wheelchair. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve elevating leg rests and an electronic connection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve elevating leg rests. 
 
You asked the Plan to pre-approve elevating leg rests. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
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 elevating leg rests. Our physician 
reviewer found that elevating leg rests can be medically necessary if the enrollee has significant edema of the 
lower extremities, if the wheelchair has a reclining back, or if the enrollee has a musculoskeletal condition or 
the presence of a cast or brace which prevents 90-degree flexion at the knee. In this case, the documentation 
available for review does not indicate the enrollee meets criteria for elevating leg rests. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of elevating leg rests have not been met. Therefore, we decided that the Plan does 
not have to pre-approve elevating leg rests.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the excision, excess skin and subcutaneous tissue; 
abdomen, infraumbilical panniculectomy (15830). 
 
You asked the Plan to pre-approve the abdominoplasty. You say that you wish to file an appeal for the denial of 
your desire to get abdominal surgery for reasons that are most medically necessary to your doctor and you. The Plan denied your request. The Plan says the abdominoplasty appears to be a cosmetic procedure and is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 abdominoplasty. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
reviewer found in this case, the record indicates that the enrollee had weight loss and is undergoing hernia 
repair. The record provided does not indicate that the enrollee has functional limitations, chronic pain, 
ulceration created by the abdominal skin fold, or intertrigo dermatitis refractory to treatment. The record 
provided is insufficient to establish the medical necessity and reasonableness, as defined by Medicare rules, of 
the requested service. The elements of the coverage criteria are not satisfied. 
 
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 abdominoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the excision, excess skin and subcutaneous tissue; abdomen, infraumbilical 
panniculectomy (15830).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for services provided on May 24, 2021, through September 22, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that your appeal was 
not submitted timely. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not forwarded any evidence to support why the 
services at issue were denied. The documentation submitted by the Plan does not include the claim or 
reconsideration request. Of note, the Plan has indicated that they issued a Notice of Dismissal due to the appeal 
request being untimely. We requested evidence of the appeal request and did not receive a response. There is 
no evidence in the file to support that the appeal was submitted untimely. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find 
in your favor. Therefore, we decided that the Plan has to pay for services provided on May 24, 2021, through 
September 22, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection(s), diagnostic or therapeutic agent, paravertebral 
facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical 
or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) (64492) 
provided June 28, 2022. 
 
You asked the Plan to pay for the injection procedure. You say that the claim was partially denied for CPT 
64492, and you do not agree with the decision and are submitting an appeal for the mentioned procedure code. 
The Plan denied your request. The Plan says the provider did not provide evidence of unique circumstances for 
a third level with sufficient documentation of medical necessity on appeal. Two levels were approved by the 
Plan. The third level remains denied. 
 
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 pay for the injection procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has thoracic back pain and received intra-articular facet injections at T4-
T5, T5-T6 and T6-T7. The third level exceeds utilization criteria and there is no reason offered why a third 
level is needed at this one session.  Therefore, the procedure was not medically reasonable and necessary. 
 
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 injection procedure have not been met. Therefore, we decided that the Plan 
does not have to pay for the injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) 
joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and 
any additional level(s) (List separately in addition to code for primary procedure) (64492) provided June 28, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214), annual wellness exam (G0438), and 
blood draw (36415) provided on January 17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management services. You say that when you signed up for 
this plan the agent advised you would keep all of your providers. You also say that this claim should be 
reprocessed and paid at the in-network rate. 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 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 office visit (99214), annual wellness exam (G0438), and 
blood draw (36415) provided on January 17, 2022, by an out-of-network (OON) provider.