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

 
We decided that the Plan does not have to waive the copayment for a primary care physician (PCP) office visit 
provided on November 30, 2021. 
 
You asked the Plan to waive the copayment for the PCP office visit. You say that you were seen for an annual 
physical and should not have a copayment. 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 $0 for an 
annual physical. If you receive services that address a medical condition during the same office visit, additional 
cost sharing may apply. 
 
Your contract with the Plan also clearly says that you must pay a $25 copayment for each visit with your PCP. 
 
The record shows that a specific medical condition (indigestion) was addressed during this visit. This service 
goes beyond the scope of an annual physical. Therefore, you have been asked to pay a $25 copayment for the 
PCP office visit. The PCP office visit falls within the Physician/Practitioner Services, Including Doctor's 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 primary care physician (PCP) 
office visit provided on November 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs amputation specific rehabilitation. 
The enrollee has recently lost weight and his prosthetic is not fitting well, and he needs physical therapy, 
occupational therapy. The Plan denied your request. The Plan says authorization denied because IRF is not 
medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing 
facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable and does not need close supervision by a physician 3 
times per week for the ongoing management of any active or acute exacerbation of chronic medical conditions. 
There are no rehabilitation nursing needs identified or documented in the record. At the current high functional 
level, the enrollee is more appropriate for a SNF rehab or in-home with therapies, and the enrollee does not 
need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach to daily therapy in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on August 30, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration for the 
denied claimed and for it to be paid. 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. 
  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 outpatient services provided on August 30, 
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 home health services provided on September 22, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that services were provided out of medical 
necessity, and you would like the Plan to retroactive an authorization for the service rendered. 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. 
 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 home health services provided on September 
22, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy services provided on May 
27, 2021 to July 9, 2021 (19 visits). 
 
You asked the Plan to waive the copayment for radiation therapy services. You say that you were told you 
would not have to pay a copayment. The Plan denied your request. The Plan says the copayment amount 
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 $50 
copayment for each Medicare-covered radiation therapy service.  
 
 
 
 
 
 You have been asked to pay a total of $950 for 19 visits of radiation therapy services. Radiation therapy 
services fall 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 radiation therapy services provided on May 27, 2021 to July 
9, 2021 (19 visits).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model with 
calibrated gradient pressure (E0652) and a segmental pneumatic appliance for use with pneumatic compressor, 
full arm (E0668) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor, segmental home model with calibrated gradient 
pressure and a segmental pneumatic appliance for use with pneumatic compressor, full arm. You say that there 
is no other supplier that is able to provide the same prescribed treatment program the provider ordered from the 
device, and you are the sole manufacturer and distributor of the prescribed device. The Plan denied your 
request. The Plan says there are in-network providers within a reasonable distance from your location that can 
provide this service/item, and they spoke with an in-network provider who confirmed they carry a pneumatic 
compression device and sleeves - specifically E0652. 
 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor, segmental home model with calibrated gradient pressure (E0652) and a segmental 
pneumatic appliance for use with pneumatic compressor, full arm (E0668) to be provided by an out-of-network 
(OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the platelet rich plasma (PRP) injection (0232T), 
ultrasonic guidance (76942), and moderate sedation (99152). 
 You asked the Plan to pre-approve the PRP injection, sedation and ultrasonic guidance. You say that the 
services are medically necessary. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 
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 PRP injection, sedation and 
ultrasonic guidance. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the current medical literature does not support the use of 
platelet rich plasma for treatment of musculoskeletal conditions outside of the realm of well-designed clinical 
trials. 
 
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 PRP injection, sedation and ultrasonic guidance have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the platelet rich plasma (PRP) injection 
(0232T), ultrasonic guidance (76942), and moderate sedation (99152).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve targeted case management to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the targeted case management. You say that the provider that you are 
requesting the enrollee to see is contracted with the Plan. The Plan denied your request. The Plan says the 
provider that you are requesting the enrollee to see is an out-of-network provider. An in-network provider has 
been contacted and they are accepting new patients. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
targeted case management to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services. 
 
You asked the Plan to pre-approve physician's services. The Plan denied your request. The Plan says the 
services are accessible in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
physician's services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for behavioral health services provided on October 14, 2021. 
 
You asked the Plan to pay for behavioral health services. The Plan denied your request. The Plan says this 
provider chose not to receive Medicare funds. 
 
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 behavioral 
health services provided on October 14, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) from 
February 1, 2022, through February 28, 2022. 
 
You asked the Plan to pre-approve the SNF admission. 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 is not 
medically necessary.  
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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You 
do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
SNF setting. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF) from February 1, 2022, through February 
28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
September 8, 2021, to September 12, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that injuries from a car 
accident were missed by the facility. You say that you had to go to another hospital for proper treatment. 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 $800 per 
day for days 1-3 and $0 per day for days 4-90 for each inpatient admission.  
 
The file shows that services were provided as an inpatient from September 8, 2021, to September 12, 2021. 
Therefore, you have been asked to pay $800 per day for the first 3 days of inpatient hospital care. The total for your stay is $2,400 ($800 copayment x 3 days = $2,400). The inpatient hospital care falls within the Inpatient 
Hospital 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 waive the copayment for inpatient hospital care 
provided from September 8, 2021, to September 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays provided on December 16, 2021. 
 
You asked the Plan to waive the copayment for x-rays. You say that your insurance is supposed to cover x-rays 
and you believe you are being charged an extra $15. The Plan denied your request. The Plan says the 
copayment 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 $15 
copayment for each Medicare-covered standard x-ray service.  
 
You have been asked to pay $30 for two x-rays ($15 x 2). X-rays fall 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 x-rays provided on December 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthroscopy, shoulder, surgical; debridement, limited (29822) 
provided on May 19, 2021 
 
You asked the Plan to pay for the arthroscopy procedure. You say that this service was necessary and was 
billed correctly. The Plan denied your request. The Plan says this service is not supported as billed. The Plan 
also states that this service was billed twice for this date; however, the second 29822 listed on this claim was 
billed inappropriately. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 29822 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
arthroscopy procedure have not been met. Therefore, we decided that the Plan does not have to pay for 
arthroscopy, shoulder, surgical; debridement, limited (29822) provided on May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 crowns (D2750), post removal (D2995 x 2), root canal 
(D3310), and post and core in addition to a crown (D2954 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says the requested 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 crowns, post removal, 
root canal, and post and core in addition to a crown are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 7 crowns (D2750), post removal (D2995 x 2), root canal 
(D3310), and post and core in addition to a crown (D2954 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150), prophylaxis - adult (D1110), and intraoral - complete series of radiographic images (D0210) 
provided November 29, 2021. 
You asked the Plan to pay for the comprehensive exam, dental cleaning, and complete series of x-rays. You say 
that you were surprised and disappointed that this claim was denied. The Plan denied your request. The Plan 
says these services are not covered because the provider has opted out of Medicare. 
 
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. The Plan covers the 
comprehensive exam, dental cleaning, and complete series of x-rays when you see any licensed dental provider 
who accepts Medicare patients in the United States and has not opted out of Original Medicare. 
 
We looked at the file and Medicare rules. 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. Based on this information, 
we decided that the Plan's rules for coverage of the comprehensive exam, dental cleaning, and complete series 
of x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation - new or established patient (D0150), prophylaxis - adult (D1110), and intraoral - complete 
series of radiographic images (D0210) provided November 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 27, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based on medical necessity. The Plan denied your request. The Plan says this has not been billed according to Medicare rules.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 27, 2021.