Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on March 31, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you should 
not be responsible to pay this. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 $250 
copayment for diagnostic radiology services that are not ultrasounds. 
 
You have been asked to pay a $250 copayment for a computed tomography (CT) scan. This item/service falls 
within the diagnostic radiology services that are not ultrasounds 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 computed tomography (CT) scan provided on March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and nail debridement services (11720, 99202) 
provided on June 3, 2022. 
 
You asked the Plan to pay for the office visit and nail debridement services. 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 as they were non-emergent and prior authorization was not 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 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 and nail debridement services 
(11720, 99202) provided on June 3, 2022.
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 IRF care to get stronger to be able 
to go home. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been 
met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service  
February 28, 2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0150) provided on June 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe that you did not exceed your dental 
limitation. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service of December 21, 2021. 
Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0150) provided on June 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on June 28, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that you do not need an authorization for the 
service that was provided to the enrollee. The Plan denied your request. The Plan says the rendering provider is 
an OON 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 nursing facility care provided on June 28, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 18, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider sent the specimen to 
your laboratory, and you would like the claim reprocessed. The Plan denied your request. The Plan says the 
rendering and referring providers are both OON providers and there was no 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 laboratory services provided on May 18, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your dentures while you were in a 
skilled nursing facility. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 12, 2018. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided on February 2, 2022. 
 
You asked the Plan to pay for prophylaxis. You say that this service is covered. The Plan denied your request. 
The Plan says the dental service was received from an out-of-network provider and is not covered by your 
supplemental 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. 
 
 
 
 
 
 
 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested item or service are not covered under this 
benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to 
pay for prophylaxis (D1110) provided on February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facial surgery on tooth #4, 5, 6, and 7 (D7950) and bone 
replacement grafts on tooth #4, 5, 6, and 7 (D7953). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with denial of dental services. 
The Plan denied your request. The Plan says facial surgery (D7950) and bone replacement grafts (D7953) are 
not covered by your dental 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 
facial surgery on tooth #4, 5, 6, and 7 (D7950) and bone replacement grafts on tooth #4, 5, 6, and 7 (D7953).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia 60MG/ML subcutaneous syringe (CPT code 
J0897). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the step criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 medication. Our physician reviewer 
found there is documentation of trial and failure of alendronate and ibandronate, but there is no indication that 
the enrollee has tried and failed zoledronic acid. Based on the medical records provided and the Medicare-
approved major drug compendia there is no indication that zoledronic acid would likely be less effective and/or 
likely have adverse effects for the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia 60MG/ML subcutaneous syringe (CPT code J0897).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an operating microscope. 
 
You asked the Plan to pre-approve an operating microscope. You say that the records supplied by your 
provider support the need for the service in dispute. The Plan denied your request. The Plan says Medicare 
states the operating microscope is not covered as a separate charge for the kind of surgery being provided. The 
Plan says that it can be used but is included in the surgery charge. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The records show that the Plan has pre-approved 
laminectomy discectomy lumbar surgery represented by code 63056. In this case, we have confirmed that code 
69990 is a column II code to column I code 63056 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an operating microscope.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit and debridement of nail(s) 
provided on June 16, 2022, by an OON provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit and debridement of nail(s) . You say to please 
review the medical records proving the service was a medical necessity.  The Plan denied your request. The 
Plan says the out-of-network services were not authorized.  
 
 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 a domiciliary or rest home visit and debridement 
of nail(s) provided on June 16, 2022, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from March 14, 2022, 
to March 16, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that these medications were all dispensed 
per your physician's and anesthesiologist's orders by the in-house pharmacy as part of your knee replacement 
procedure. The Plan denied your request. The Plan says the self-administered drugs are not covered by 
Medicare or by your healthcare plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from March 14, 2022, to March 16, 2022.  
 Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on June 29, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you are appealing because you were 
informed there would be a $0 copayment for the injection. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
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 20% 
coinsurance for other Medicare Part B drugs.  
 
You have been asked to pay a coinsurance of $255.12, which is 20% of the allowed amount for an injection 
($1,275.60 x 20% = $255.12). This item/service falls within the Medicare Part B Prescription Drugs benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for an injection provided on June 29, 2022.  
 Your complaint about being informed there was no copayment for an injection is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 22, 2021. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 the 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 provided on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a panoramic x-ray 
(D0330) provided on May 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested items or services has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for a limited oral evaluation was exhausted on date of service January 10, 2022, and your 
benefit for a panoramic x-ray was exhausted on date of service February 12, 2021. Therefore, we decided that 
the Plan does not have to pay for a limited oral evaluation (D0140) and a panoramic x-ray (D0330) provided on 
May 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service April 4, 
2022. 
 
You asked the Plan to pay for procedure code 93042. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 93042 is bundled into payment for code 12011. 
 
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 12011. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93042 billed for date of service April 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on June 15, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $385 
copayment for each Medicare-covered trip (one-way). Covered ambulance services include fixed wing, rotary 
wing, and ground ambulance services, to the nearest appropriate facility that can provide care if they are 
furnished to a member whose medical condition is such that other means of transportation could endanger the 
persons health or if authorized by the plan. 
 
You have been asked to pay a $385 copayment for ambulance. This item/service 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 on June 15, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia provided on March 22, 2022, by an OON 
provider. 
 
You asked the Plan to pay for anesthesia. You say that the records should be reviewed for medical necessity. 
The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 anesthesia provided on March 22, 2022, by an 
OON provider.