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

 
We decided that the Plan does not have to waive the copayment for a physical medicine specialist office visit 
provided on November 11, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that the visit was to receive an 
injection in your hip and the specialist would not give it to you. You also say you should not be responsible for 
the copayment for simply walking into a room to be told the provider was not going to give you the injection 
you were there for. 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 $40 
copayment for a specialist office visit.  
 The medical record shows you had a specialist office visit on November 11, 2021. You have been asked to pay 
a $40 copayment for a specialist office visit. A specialist office visit 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 a physical medicine specialist office visit provided on November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on November 18, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this provider is credentialed per the Plan's 
guidelines, and you want this claim processed without the authorization since this is a network provider. The 
Plan denied your request. The Plan says this provider's effective date with the Plan is after the claim's date of 
service, therefore on the date of service, the provider was still non-participating with the Plan. The Plan also 
says that this provider is not a network provider with the Plan and the services were not referred by a network 
provider or rendered in an in-network facility. The Plan also says that they have also determined that these 
services are not urgent or emergent, nor were they approved in advance. 
 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 (99214) provided on November 18, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for assistant at surgery services at an unlisted procedure (64999) provided
on November 18, 2021.
You asked the Plan to pay for assistant at surgery services. You say that the services at issue were a medical
necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met.
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 case record does not contain a copy of the medical records
provided to the Plan for use in its review. It is the Plan's responsibility to substantiate its denial. In this case the
denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay
for assistant at surgery services at an unlisted procedure (64999) provided on November 18, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (71045) provided on December 19, 2021. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 71045 
is a column II code to column I code 32555. 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 the services (71045) provided on December 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sliding shower bench and wheelchair ramp. 
 
You asked the Plan to pre-approve a sliding shower bench and wheelchair ramp. You say that the items are 
necessary. The Plan denied your request. The Plan says the requested items are not primarily medical in nature. 
 
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 a sliding shower bench and wheelchair ramp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high strength lightweight wheelchair. 
 
You asked the Plan to pre-approve a high strength lightweight wheelchair. You say that you are having right 
hip surgery and will require a wheelchair. The Plan denied your request. The Plan says that without medical 
notes from the doctor who requested the wheelchair, we cannot determine if the wheelchair is medically 
needed. 
 
The Plan must follow Medicare rules. Medicare rules say that a high strength lightweight wheelchair can be 
covered if Medicare criteria are met. 
 
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 high strength lightweight wheelchair. 
Our reviewer says that a high strength lightweight wheelchair is not considered medically reasonable and 
necessary in this case. The documentation does not support that you have a mobility limitation that 
significantly impairs her ability to participate in one or more mobility-related activities of daily living 
(MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. The 
documentation does not support that your mobility limitation cannot be sufficiently resolved by the use of an 
appropriately fitted cane or walker or that your home provides adequate access between rooms, maneuvering 
space, and surfaces for use of the manual wheelchair that is requested. The documentation does not support that 
the use of a manual wheelchair will significantly improve your ability to participate in MRADLs and that you 
will use it on a regular basis in the home. There is no objective physical examination revealing that you have 
sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the 
manual wheelchair that is provided in the home during a typical day. There are no objective exam findings of 
strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both 
upper extremities. There is no evidence that you are unable to engage in activities in the home that cannot be 
performed in a standard or lightweight wheelchair. The documentation does not support that you require a seat 
width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair, and spends 
at least two hours per day in the wheelchair. Our physician reviewer found that your condition does not meet 
Medicare criteria for a high strength lightweight 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 a high strength lightweight wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a high strength lightweight wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core buildup, including any pins when required (D2950) 
provided on January 31, 2022. 
 
You asked the Plan to pay for a core buildup. You say that you are requesting reconsideration for payment of 
claim. The Plan denied your request. The Plan says the requested service is not listed as a covered benefit with 
your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a core 
buildup, including any pins when required (D2950) provided on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration - resorbable barrier, per site 
(D4266) and bone replacement graft for ridge preservation - per site (D7953). 
 
You asked the Plan to pre-approve guided tissue regeneration and bone replacement graft. You say that you 
would like these services covered. The Plan denied your request. The Plan says these services are not covered 
under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
guided tissue regeneration - resorbable barrier, per site (D4266) and bone replacement graft for ridge 
preservation - per site (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutment (D6057) and implant supported crown 
(D6066) for tooth # 13. 
 
You asked the Plan to pre-approve the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says dental implants and associated services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested custom abutment and 
implant supported crown are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve custom abutment (D6057) and implant supported crown (D6066) for tooth # 13.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit on October 18, 2021. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you did not go to the 
emergency room, you went to urgent care. The Plan denied your request. The Plan says the copayment 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 $120 
copayment for each emergency room visit.  
 
You have been asked to pay $120 copayment for the emergency room visit. The emergency room visit falls 
within the Emergency Care benefit category. The medical records show you were seen in the emergency 
room. 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 emergency room visit on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2752), a core build-up (D2950), and desensitizing 
resin (D9911) provided by a participating provider on April 20, 2021. 
 
You asked the Plan to pay for a crown, a core build-up, and desensitizing resin. You say that you thought you 
had a $500 dental benefit. The Plan denied your request. The Plan says you do not have supplemental dental. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
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. Therefore, we decided that the Plan does not have to pay for a crown (D2752), a core build-up 
(D2950), and desensitizing resin (D9911) provided by a participating provider on April 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator, single delivery port (E1390) 
purchased July 1, 2021. 
 
You asked the Plan to pay for the oxygen concentrator. You say that you have difficulty with your lungs due to 
having COVID. You were sure that the portable oxygen is covered by the Plan. You are dependent on the O2 
machine. The Plan denied your request. The Plan says the item was purchased from a supplier who is not 
certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator, single delivery 
port (E1390) purchased July 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) sessions. 
 
You asked the Plan to pre-approve the requested PT services. You say that the enrollee has been receiving PT 
and requires ongoing treatment to reach goals. The Plan denied your request. The Plan says further PT is not 
shown to be medically necessary at this time as the enrollee has not been able to progress toward goals. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT services. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific and effective therapy for the patients condition beyond what was approved by the plan. The patient 
has had prior therapy, and the documentation does not reveal that the patient requires the unique skills of a 
professional therapist to safely and effectively provide treatment, or that the services can be safely and 
effectively performed only by a therapist or under the supervision of a therapist. The patient can follow up with 
her physician for adjustments to her treatment plan. The requested services are not part of a maintenance 
program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design and/or deliver a program to maintain the patient's current condition or to prevent or slow further 
deterioration. 
 
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 PT services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional physical therapy (PT) sessions.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve the FoundationOne Liquid CDx test provided to the enrollee on 
September 13, 2021. 
 
You asked the Plan to pre-approve the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says that as per a review of the literature and clinical practice guidelines, there is a lack of 
clinical utility in plasma-based comprehensive genomic profiling when further chemotherapy is not being 
pursued. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically 
necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the testing. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee with metastatic prostate cancer does meet the criteria for this testing. Specifically, he has 
evidence of disease progression with current androgen blockade and FoundationOne Liquid CDx test provided 
to the enrollee on September 13, 2021 is needed to determine whether additional chemotherapy is indicated. 
 
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 testing have been met. Therefore, we decided that the Plan has to pre-
approve the FoundationOne Liquid CDx test provided to the enrollee on September 13, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (S9346) provided from November 3, 2021, to 
November 24, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee 
Schedule indicates that the code in question is not valid for Medicare purposes.  
 
We looked at the file and Medicare rules. Code S9346 is assigned a status indicator of I under the Physician 
Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for 
reporting of, and payment for, these services. 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 pay for the 
services (S9346) provided from November 3, 2021, to November 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile gauze, non-impregnated (A6219) provided on 
November 26, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the sterile gauze. You say that the supplies were provided in a network facility at 
the direction of a network provider. Therefore, the Plan should reimburse you for the items your provided. 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 the sterile gauze, non-impregnated (A6219) 
provided on November 26, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99283) provided on October 15, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 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 99283 
is a column II code to column I code 99284. 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 the services (99283) provided on October 15, 2021.