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

 
We decided that the Plan does not have to pay for a laboratory drug test provided on October 21, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory drug test. 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 a laboratory drug test provided on October 21, 
2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy (15830, 15847). 
 
You asked the Plan to pre-approve the panniculectomy. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 panniculectomy. Our reviewer says 
that this procedure is not medically necessary. Our reviewer found the pictures submitted with the record do 
not document that the pannus is below the pubic symphysis. The record provided does not document the 
presence of intertrigo refractory to conservative treatment or the presence of functional limitations. 
 
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 panniculectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a panniculectomy (15830, 15847).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series 
of intraoral x-rays (D0210), topical application of fluoride varnish (D1206), resin-based composite (D2392), 
crown (D2740), core buildup, including any pins when required (D2950), and three periodontal scalings and 
root planings (D4342 x3) provided on April 8, 2022, and April 19, 2022, by an out-of-network (OON) 
provider. 
 
  You asked the Plan to pay for the dental services. You say that the Plan provided no communication notifying 
that the treating provider is OON with the enrollee's plan. The Plan denied your request. The Plan says the 
dental services were received from an OON provider and are not covered by the enrollee's supplemental 
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. 
 
The record shows the enrollee received the requested dental services from an OON provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an OON provider. Therefore, we decided that the Plan does not have to pay for 
the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), topical application of 
fluoride varnish (D1206), resin-based composite (D2392), crown (D2740), core buildup, including any pins 
when required (D2950), and three periodontal scalings and root planings (D4342 x3) provided on April 8, 
2022, and April 19, 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 laboratory services related to end-stage renal disease 
(ESRD) provided on February 16, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit (99214) provided on October 
26, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as 
you disagree with the charges. 
 The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 $35 
copayment for Physician/Practitioner services, including doctors office visits, specifically specialist visits.  
 
 
  You have been asked to pay $24.26 copayment for the office 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 office visit (99214) provided on October 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra battery for a nerve stimulator (L8683). 
 
You asked the Plan to pre-approve the extra battery. You say that the extra battery is medically necessary. The 
Plan denied your request. The Plan says the requested extra battery is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an extra battery for a nerve stimulator (L8683).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Lumbar-sacral orthosis (L0650) provided on January 24, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. 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 Lumbar-sacral orthosis (L0650) provided on 
January 24, 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 an electronic analysis of implanted neurostimulator (95983) 
provided on February 17, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the electronic analysis of implanted neurostimulator. 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 an electronic analysis of implanted 
neurostimulator (95983) provided on February 17, 2022 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 eyeglasses purchased on November 1, 2021. 
 
You asked the Plan to pay for the eyeglasses. You say that you were diagnosed with Diplopia prior to your 
cataract surgery, and needed glasses immediately at that time. The Plan denied your request. The Plan says 
there are no supplemental benefits that cover eyeglasses other than after cataract surgery. 
 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 these services when the eyeglasses are purchased after the cataract surgery. 
 
We looked at the file and the Plan's rules. The record shows that you received cataract surgery on December 7, 
2021, and December 21, 2021. You purchased these glasses on November 1, 2021, which is prior to both 
cataract surgeries. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses 
have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses purchased on 
November 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided on April 13, 
2022, by an out-of-network provider. 
 
You asked the Plan to pay for SNF care. The Plan denied your request. The Plan says non-urgent services were 
provided by a non-participating provider and 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 skilled nursing facility (SNF) care provided on 
April 13, 2022, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for continuous positive airway pressure 
(CPAP) device on February 02, 2022, to April 02, 2022. 
 
You asked the Plan to waive the coinsurance for continuous positive airway pressure (CPAP) device. You say 
that the bill from Rotech should be paid. 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 20% 
coinsurance for durable medical equipment provider. On February 02, 2022, the provider billed in the amount 
of $486.85 and the allowed amount is $32.81. $32.81 x 20% = $6.56. The provider also billed in the amount of 
$553 and the allowed amount is $178.02. $178.02 x 20% = $35.61. On March 02, 2022, the provider billed in 
the amount of $153 and the allowed amount is $44.99. $44.99 x 20% = $9. On April 02, 2022, the provider 
billed in the amount of $153 and the allowed amount is $44.99. $44.99 x 20% = $9. $6.56 + $35.61 + $9 + $9 
= $60.17. 
 You have been asked to pay a 20% coinsurance for continuous positive airway pressure (CPAP) device. 
Continuous positive airway pressure (CPAP) device 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 (CPAP) device on February 02, 2022, to April 02, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 22, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service April 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on March 24, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the ophthalmological 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 ophthalmological services provided on March 24, 
2022 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visit (99334) provided on September 2, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the rest home visit. 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 rest home visit (99334) provided on September 2, 
2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on March 
12, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this should be covered. 
The Plan denied your request. The Plan says you were charged this cost sharing 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 $150 
copayment for each ambulance trip. You had one ambulance trip(s). The Plan charged you $150 for these 
services. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the ambulance services provided on March 12, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has anemia secondary to 
chemotherapy for metastatic adenocarcinoma of the colon and chronic kidney disease. She has not tried and 
failed the Plan's required drugs, Retacrit or Procrit. The records do not show that the required drugs would be 
contraindicated or less effective; therefore, Aranesp is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aranesp.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018 billed for date of service April 15, 
2022. 
 
You asked the Plan to pay for procedure code 74018. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 74018 is bundled into payment for code 74022.  
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 74018 
is a column II code to column I code 74022. 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 74018 billed for date of service April 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on March 9, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you think this was coded 
incorrectly because you thought it was supposed to be covered. 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 $395 
copayment for each Medicare covered outpatient hospital visit.  
 
You have been asked to pay $395 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient Surgery, Including 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 outpatient surgery provided 
on March 9, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an outpatient mental health visit provided 
on March 15, 2022. 
 
You asked the Plan to reduce the copayment for an outpatient mental health visit. You say that you were told 
there would be a $15 copayment since this was not a doctor visit but a nurse for counseling. 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 $40 
copayment for in-network mental health services at specialist office or partial hospitalization.  
 
You have been asked to pay a $40 copayment for an outpatient mental health visit. An outpatient mental health 
visit falls within the Outpatient Mental Health 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 reduce the 
copayment for an outpatient office visit provided on March 15, 2022.