Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on January 19, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that the member should not have to 
change their existing provider. 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 outpatient mental health services provided on 
January 19, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral positive airway pressure (BiPAP) for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that the enrollee is unable to find a mask that is well-
tolerated. The Plan denied your request. The Plan says there is no medical need for this. 
 
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 pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee states that BiPAP is more comfortable than continuous positive airway pressure (CPAP) 
after using it for a few minutes while awake. The usage download 7/19 - 8/17/22 indicates the patient is using 
CPAP and that it is effective. BiPAP would be indicated if CPAP were not effective during a CPAP titration 
study. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bilateral positive airway pressure (BiPAP) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care (99291) provided on November 25, 2021. 
 
You asked the Plan to pay for observation care. You say that this is supported in the records. The Plan denied 
your request. The Plan says this cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management 
(face-to face) service is provided on the same day to the same patient by the same physician or more than one 
physician in the same specialty in the same group, only one evaluation and management service may be 
reported. 
 
We looked at the file and Medicare rules. An observation evaluation and management code has already been 
billed and paid for this date of service and practice. Based on this information, we decided that Medicare rules 
for coverage of observation care have not been met. Therefore, we decided that the Plan does not have to pay 
for observation care (99291) provided on November 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray on April 18, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you already paid a copayment of $45, 
and you didnt 
know you had to pay a separate payment for an x-ray. The Plan denied your request. The Plan says due to the 
Medicare allowable rate being less than your full copayment of $60 for x-ray services, the claim is processing 
with a copayment of $57.44. 
 
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 $60 
copayment for an x-ray. Since the allowable amount is less than the $60 copayment, the amount owed is 
$57.44. 
 
You have been asked to pay a $60 copayment for an x-ray. An x-ray 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 on April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Botox injections provided on March 15, 
2022. 
 
You asked the Plan to waive the coinsurance for Botox injections. You say that you get these injections for 
headaches. The last time you had this done, the copayment was much less. The Plan denied your request. The 
Plan says the coinsurance that was applied was 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 Medicare part b prescription drugs. The allowed amount of this drug is $1,218.00, resulting in a 
$243.60 coinsurance ($1,218.00 x 20% = $243.60). 
 
You have been asked to pay a $243.60 coinsurance for Botox injections. Botox injections falls within the 
Medicare part b prescription drugs benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
Botox injections provided on March 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for miscellaneous medical services (99999) provided on April 
21, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that before getting tested you communicated 
with the office in Puerto Rico and was informed that you had to pay for the test and the Plan will reimburse you 
when the request of reimbursement is sent. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before 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 miscellaneous medical services (99999) provided 
on April 21, 2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided September 21, 2021 to September 27, 
2021. 
 You asked the Plan to pay for the inpatient care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the diagnosis code billed is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principle diagnosis code A41.9. 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 inpatient care. Our reviewer says that the records do not 
support the diagnosis code billed. Our physician reviewer found although the enrollee reported disorientation 
during the hospital stay, this alone would not meet Sepsis 3 criteria which requires a rise of Sequential Organ 
Failure Assessment (SOFA) score of 2 or more points related to the infection.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient care provided September 21, 2021 to September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network (OON) home health 
visit and services provided on June 27, 2022. 
 
You asked the Plan to waive the coinsurance for a home health visit and services. You say that you are unable 
to pay the out-of-network coinsurance and would like your portion of the coinsurance to be billed as in-
network. The Plan denied your request. The Plan says the coinsurance applied was 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% 
coinsurance for Out-of-Network Home Health Care and a $25 copayment for Out-of-Network Provider and 
Professional Services.  
 
You have been asked to pay $130.39 which is 40% of the allowed amount for OON home health services 
($325.98 allowed amount x 40% coinsurance = $130.39). You have also been asked to pay a $25 copayment 
for an OON home health visit. You have been asked to pay a total of $155.39 ($130.39 coinsurance + $25 
copayment = $155.39).  Home health visits and services fall within the Home Health Agency Care and Physician/Practitioner Services, 
Including Doctor's Office Visits, benefit categories. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
an out-of-network home health visit and services provided on June 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes. 
 
You asked the Plan to pre-approve the shoes. You say that it is felt that these shoes are needed. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for the requested items. 
 
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 pre-approve the shoes. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that it is well established that this patient is diabetic. They do see their internist for diabetic care. There 
are three podiatry progress notes enclosed for review. Each note advises that the patients pedal pulses are 
palpable and epicritic sensation is intact bilateral feet. Medicare guidelines advise that in order for diabetic 
shoes to be covered the patient must be under treatment for their diabetes. They must also have any of the 
following conditions: previous amputation of other foot, or part of either foot, or a history of previous foot 
ulceration of either foot, or history of pre-ulcerative calluses of either foot, or peripheral neuropathy with 
evidence of callous formation of either foot, or foot deformity of either foot, or poor circulation in either foot. 
The enclosed medical documentation does not substantiate any of the above-mentioned criteria for coverage. 
 
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 shoes have not been met. Therefore, we decided that the Plan does not have 
to pre-approve diabetic shoes.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) provided on May 9, 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 prior authorization was not obtained before the service 
was 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 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 (99204) provided on May 9, 2022, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay the full allowed amount for the glasses provided on May 14, 2022. 
 
You asked the Plan to pay more for the glasses. You say that your coverage states that it will cover up to $400 
for glasses. You also say that a $130 difference has been left, which should be covered. The Plan denied your 
request. The Plan says that the copayment amount assessed of $136 was applied correctly. 
 
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 up to a $450 allowance every year for routine eyewear provided in-network. 
 
We looked at the file and the Plan's rules. The record shows that you received these eyeglasses from an in-
network provider. The total allowed amount for these glasses was $406, which is less than the $450 allowance 
offered by the Plan, and you were asked to pay $136. There is no evidence in the documentation showing you 
have met your routine eyewear allowance. You cannot be held responsible for the difference between the Plan 
payment and the allowed amount since your full eyewear allowance had not been met yet. Based on this 
information, we decided that the Plan's rules for additional coverage of the glasses have been met. Therefore, 
we decided that the Plan has to pay the full allowed amount for the glasses provided on May 14, 2022.  
 
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 services billed with codes 24341 and 29827 provided on 
January 26, 2022. 
 
You asked the Plan to pay for codes 24341 and 29827. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 24341 and 29827 are not supported in the medical record. Specifically, the operative 
report did not include documentation of a primary or secondary repair of a tendon or muscle in the upper arm 
or elbow for each tendon or muscle (excludes rotator cuff); therefore, code 24341 is not supported. The 
operative report did not include documentation of a surgical shoulder arthroscopy, with rotator cuff repair; 
therefore, code 29827 cannot be verified. Based on this information, we decided that Medicare rules for coverage of codes 24341 and 29827 have not 
been met. Therefore, we decided that the Plan does not have to pay for services billed with codes 24341 and 
29827 provided on January 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a power wheelchair. You say that you have a hernia as large as a human 
head weighing you down and you are not able to walk by yourself or with a walker. You also say that you are 
in pain due to the weight of the hernia and feel a lack of life quality. You would like to be able to walk your 
dogs to keep healthy and independent but is not able to without such DME. The Plan denied your request. The 
Plan says the requested wheelchair is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 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 a power wheelchair. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee is not impaired in 
capacity to perform mobility related ADLs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power operated vehicle, group 1 standard, patient weight capacity up to and 
including 300 pounds (K0800).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs and outpatient 
dialysis services provided on December 1, 2021. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs and outpatient dialysis services. You 
say that the enrollee had met his out-of-pocket maximum in 2021 and would not need to pay any further costs 
for services in 2021. The Plan denied your request. The Plan says the claim processed with the correct cost 
share. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for Medicare Part B Prescription Drugs and Services to Treat Kidney Disease.  
 
The enrollee has been asked to pay a 20% coinsurance for Medicare Part B drugs and outpatient dialysis 
services. Medicare Part B drugs and outpatient dialysis services falls within the Medicare Part B Prescription 
Drugs and Services to Treat Kidney Disease benefit category.  This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs and outpatient dialysis 
services provided on December 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve ablation procedure (64624). 
 
You asked the Plan to pre-approve the genicular nerve ablation procedure. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says this procedure is experimental and non-
covered. 
 
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 pre-approve the genicular nerve ablation procedure. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the role of this procedure in the treatment of osteoarthritis of the knee is 
still being considered. More research is needed to show safety and efficacy of this procedure. 
 
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 genicular nerve ablation procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a genicular nerve ablation procedure (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 11, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the service is not 
covered under the members contact under any normal circumstances. Per the members 2022 Evidence 
of Coverage the Plan has limited chiropractic benefits and this service is excluded. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on March 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service March 2, 
2022 to March 3, 2022. 
 
You asked the Plan to pay for procedure code 93042. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 93042 is bundled into payment for code 93010. 
 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 93042 
is a column II code to column I code 93010. 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 93042 billed for date of service March 2, 2022 to 
March 3, 2022.