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

 
We decided that the Plan does not have to pay for physician's services provided on December 16, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says there is no 
payment for providers that have opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services provided on December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on October 21, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for podiatry services. You say that the services were medically necessary and should 
be paid by the Plan. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because this provider is out-of-network with the Plan and the ordering physician was also out-of-
network with the Plan. 
 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 podiatry services provided on October 21, 2021 by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthopedic footwear, ladies shoe, oxford (L3215) purchased 
November 5, 2021. 
 
You asked the Plan to pay for foot orthotics. You say that you were told that you would be reimbursed the $180 
for shoes as you are not diabetic and did not need according to guidelines corrective shoes. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
 
 
 
 
 
 
 Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for orthopedic footwear, ladies shoe, 
oxford (L3215) purchased November 5, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. You are walking 
household distances with a wheeled walker with minimum assistance with voice cues and is minimum assist 
for transfers. Provided records do not document a significant decline in your functional status compared to your 
recent baseline to necessitate daily inpatient skilled therapy services. You do not require the services on an 
inpatient basis, only in a skilled nursing facility setting. Records do not document that services in the home 
with home health care or in a long-term care facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for An office visit 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 you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says prior authorization is required for 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 An office visit provided on November 18, 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 breast biopsy and related services provided on December 6, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the breast biopsy and related services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for breast biopsy and related services provided on December 6, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 1, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an appropriate modifier was not billed. 
 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 12051. 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 imaging services provided to the enrollee on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the office visit on February 9, 2022. 
 
You asked the Plan to reduce the copayment for office visit. You say that the provider is in-network and the 
copayment should be $10. 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 $15 
copayment for each out-of-network office visit.  
 
You have been asked to pay $15 copayment for the out-of-network office visit. The out-of-network 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 reduce the copayment for the office visit on February 9, 
2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the professional component of the extremity angiography services 
provided on April 23, 2021, billed with codes 75710-26-59. 
 
You asked the Plan to pay for the billed angiography services. You say that this should be paid as billed. The 
Plan denied your request. The Plan says that the use of modifier -59 is not supported in this case. 
 
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 75710 
is a column II code to column I code 37221; however, 75710 was billed with a modifier. 
 
We asked our coder 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 billed angiography services. Our reviewer says that the 
documentation supports separate payment for code 75710. Our reviewer found the documentation provided 
was reviewed, and it was found that criteria for separate payment have been met. This procedure would be 
separately reported, as CPT 37221 does not include radiology services.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed angiography services have been met. Therefore, we decided that the 
Plan has to pay for the professional component of the extremity angiography services provided on April 23, 
2021, billed with codes 75710-26-59.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services, medical examination and 
evaluation provided on December 28, 2021. 
 
You asked the Plan to pay for ophthalmological services, medical examination and evaluation. The Plan denied 
your request. The Plan says this provider is not a Medicare enrolled provider and as such is not eligible for 
reimbursement from Medicare for services rendered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
ophthalmological services, medical examination and evaluation provided on December 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), complete 
denture - maxillary (D5110), mandibular partial denture - cast metal framework with resin denture bases 
(including retentive/clasping materials, rests and teeth) (D5214) and alveoloplasty in conjunction with 
extractions - four or more teeth or tooth spaces, per quadrant (D7310) provided January 7, 2022. 
 
You asked the Plan to pay for the tooth extractions, complete upper denture lower partial denture and 
alveoloplasty. You say that you cannot afford the cost of the services. 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 Plan's 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 the 
extractions, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of 
mucoperiosteal flap if indicated (D7210), complete denture - maxillary (D5110), mandibular partial denture - 
cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) 
and alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7310) 
provided January 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0482) provided July 14, 2021. 
 
You asked the Plan to pay for lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of lab services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for lab services (G0482) provided July 14, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for a peripheral nerve block (64447). We decided that the Plan does not 
have to pay for sciatic nerve injections (64445).  
 
You asked the Plan to pay for the surgical services. You say that these services were medically necessary. The 
Plan says that the services are not separately payable. 
 
We decided that the Plan has to pay for a peripheral nerve block (64447). The use of modifier 59 to show a 
separate and distinct service is supported in the records. Therefore, we decided that the Plan has to pay for code 
64447.  
 
 
 
 We also decided that the Plan does not have to pay for a sciatic nerve injection (64445). The provided 
records do not support the billed code. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on August 31, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiology services. You say that you are the only provider that services the 
skilled nursing facility (SNF), and it was medically necessary to treat the enrollee. The Plan denied your 
request. The Plan says the rendering provider is an out-of-network provider and there was no referral from an 
in-network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
Additionally, on the claim form it shows the service was performed in an office setting and not in the SNF. 
 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 radiology services provided on August 31, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a lumbar x-ray provided on September 23, 
2021. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you are requesting complete research of 
these claim issues with an explanation in writing. You also say you request a complete refund, or that your 
account be credited. 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 $15 
copayment for in-network standard x-ray service.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$15 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 a lumbar x-ray provided on 
September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the second stage implant surgery (D6011), custom fabricated 
abutment - includes placement (D6057), abutment supported porcelain/ceramic crown (D6058) and labial 
veneer (porcelain laminate) - laboratory (D2962) provided October 28, 2020, to November 16, 2021. 
 
You asked the Plan to pay for the second stage implant surgery, custom fabricated abutment, abutment 
supported crown and labial veneer. 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 Plan's 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 the 
second stage implant surgery (D6011), custom fabricated abutment - includes placement (D6057), abutment 
supported porcelain/ceramic crown (D6058) and labial veneer (porcelain laminate) - laboratory (D2962) 
provided October 28, 2020, to November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the limited bilateral noninvasive 
physiologic studies of the upper or lower extremity arteries (93922) provided on September 2, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
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 a $105 
copayment for Medicare-covered radiological services, not including x-rays, performed in a physicians office 
or at a free-standing facility (such as a radiology center or medical clinic).   
 You have been asked to pay $90.44 for the Medicare-covered radiological services provided. This is the Plans 
allowed amount for these services which is less than the applicable copayment. 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 limited bilateral noninvasive physiologic studies of the upper or lower 
extremity arteries (93922) provided on September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 8, 2021. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says prior authorization 
was not obtained by the provider. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on October 8, 2021.