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

 
We decided that the Plan does not have to pay for an office visit provided on April 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting documentation. 
The Plan denied your request. The Plan says 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 provided on April 4, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited re-evaluation (D0170) provided 
on April 20, 2022. 
 
You asked the Plan to pay for the problem focused limited re-evaluation. You say that you cannot afford to pay 
this bill. The Plan denied your request. The Plan says this service is not covered under the 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 the 
problem focused limited re-evaluation (D0170) provided on April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on February 23, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the provider depends on the hospital staff to 
verify eligibility and to obtain proper authorization. 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 
domiciliary visit. We found no exception that would require the Plan to pay for the domiciliary visit. The 
records provided for review do not show that the domiciliary visit was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on February 23, 2022, 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 a specialist office visit provided on July 27, 
2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that this copayment should be 
a lower amount. 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 $40 
copayment for physician specialist services.  
 
You have been asked to pay a $40 copayment for a specialist office visit. A specialist office visit falls within 
the Physician Specialist Services (Including Surgery Second Opinion, Medicare-Covered Telehealth or 
Urgently Needed Services) 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 specialist 
office visit provided on July 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomographic (CT) angiography, abdominal aorta 
and bilateral iliofemoral lower extremity runoff, with contrast (75635) provided on June 10, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for CT scan. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the services were rendered with an out-of-network provider. The services were 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 computed tomographic (CT) angiography, 
abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast (75635) provided on June 10, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ablation of malignant prostate tissue. 
 You asked the Plan to pre-approve prostate tissue ablation. You say that there is a large body of evidence 
supporting this therapy for a patient such as this enrollee. The Plan denied your request. The Plan says this 
procedure is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that ablation of malignant prostate tissue with high-
intensity focused ultrasound (HIFU) is only covered for enrollees with recurrent prostate cancer post-radiation 
therapy who meet specified criteria. 
 
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 prostate tissue ablation. Our reviewer 
says that the enrollee does not meet the Medicare criteria for ablation of malignant prostate tissue. Our 
physician reviewer found the records do not show that the enrollee has recurrent prostate cancer following 
radiation therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostate tissue ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ablation of malignant prostate tissue.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat left knee genicular nerve ablation. 
 
You asked the Plan to pre-approve a repeat left knee genicular nerve ablation. The Plan denied your request. 
The Plan says a repeat left knee genicular nerve ablation is 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 a repeat left knee genicular nerve 
ablation. Our reviewer says that a repeat left knee genicular nerve ablation is not considered medically 
reasonable and necessary in this case. Our physician reviewer found the role of RFA of the genicular nerves is 
still being elucidated. It is considered experimental/ investigational at this point. Therefore, the request is 
considered not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a repeat left knee genicular nerve ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a repeat left knee genicular nerve ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visist. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly the provider is not 
in-network with the plan and care can be provided 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 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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 30, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 30, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services 
and the home visit provided on March 2, 2022, to April 13, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical services and the home visit. 
You say that the provider is in the process of contracting and is currently out-of-network under the product line. 
You say no other psychiatric nurse practitioners were available to treat the enrollee at the facility. 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 
psychiatric diagnostic evaluation with medical services and the home visit. We found no exception that would 
require the Plan to pay for the psychiatric diagnostic evaluation with medical services and the home visit. 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 the psychiatric diagnostic evaluation with medical services and 
the home visit provided on March 2, 2022, to April 13, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
October 2, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you do not 
understand why the charges are so high. 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 $225 
copayment for each one-way ground ambulance trip.  
 
You have been asked to pay a $225 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance Services 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 ambulance transportation provided on October 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 
 
We decided that the Plan does not have to waive the $222.58 deductible for an ultrasound performed on April 
5, 2022. 
 
You asked the Plan to waive the $222.58 deductible for an ultrasound. You say that you should only have to 
pay the copayment. The Plan denied your request. The Plan says your in-network deductible is $450. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $222.58 deductible which applies to an ultrasound.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $450 deductible which applies to Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies. This cost sharing is a contractual obligation that had not been met at the 
time an ultrasound was received on April 5, 2022. 
 
 
 
 
  Therefore, we decided that the Plan does not have to waive the $222.58 deductible for an ultrasound 
performed on April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two retainers (D6545 x2) or pay more for the pontic 
(D6242) provided on December 16, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the retainers and to pay more for the pontic. You say that you were not aware 
that the treating provider was OON. You also say that you would not have used this provider if you had known. 
The Plan denied your request. The Plan says the retainers are not covered under your plan. The Plan also says 
that you were seen by an OON provider, and the Plan only pays up to a certain amount. 
 
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 retainers are not among those 
covered under this benefit. You are also responsible for the difference between the billed amount and allowed 
amount for the pontic because it was received OON. Therefore, we decided that the Plan does not have to pay 
for the two retainers (D6545 x2) or pay more for the pontic (D6242) provided on December 16, 2021 by an 
out-of-network (OON) provider.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the medical criteria for an IRF admission has not been met. 
 
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 was admitted for syncope and closed head injury. The enrollee's medical 
problems are stable and there are no complex nursing or rehabilitation needs.  
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical preparation or creation of recipient site by 
excision of open wounds provided on March 17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical preparation or creation of recipient site by excision of open wounds. 
You say that you are appealing with supporting records. The Plan denied your request. The Plan says the 
services are not authorized because this provider is a non-network provider who does not work with the Plan, 
and the member was referred by a provider who also does not work with the Plan. The Plan also says that the 
member's primary care physician did not refer for services. 
 
 
 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 surgical preparation or creation of recipient 
site by excision of open wounds provided on March 17, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a permanent cardiac contractility 
modulation system. 
 
You asked the Plan to pre-approve cardiac contractility modulation system. You say that this is an approved 
procedure that is medically necessary. The Plan denied your request. The Plan says the denial of authorization 
for this service is correct, because a scientific assessment of this technique has not been completed. 
 
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 cardiac contractility modulation system. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found multiple observational studies suggest clinical benefit from clinical 
contractility modulation (CCM). While studies led to Food & Drug Administration (FDA) approval in 2019, 
CCM remains the subject of multiple studies examining long-term efficacy as well as randomized, controlled, 
double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is 
premature to presume clinical benefits and outcomes. The CCM system would not be considered medically 
necessary at this time.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac contractility modulation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve insertion of a permanent cardiac contractility modulation 
system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on May 
14, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that this copayment should be 
waived. 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 $40 
copayment for Physician/Practitioner service.  
 
You have been asked to pay the allowed amount of $22.18 which is less than the $40 copayment for a specialist 
office visit. A specialist office visit falls within the Physician/Practitioner Service 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 specialist office visit provided on May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a surgical follow up provided on April 11, 
2022. 
 
You asked the Plan to waive the copayment for a surgical follow up. You say that you should not have to pay a 
copayment for these follow up appointments. 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 $40 
copayment for each specialist's office visit.  
 
You have been asked to pay a $40 copayment for a surgical follow up. A surgical follow up falls within the In-
Network Specialist's Office Visit 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 
surgical follow up provided on April 11, 2022.