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

 
We decided that the Plan does not have to pre-approve Spironolactone tablets. 
 
You asked the Plan to pre-approve Spironolactone tablet. The Plan denied your request. The Plan says 
Spironolactone tablet is a self-administered drug, and does not fall under Part B coverage. 
 
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 pre-approve Spironolactone tablets.  
 
  Benefits for Spironolactone tablet 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment billed for date of service June 
6, 2022. 
 
You asked the Plan to pay for the billed services. You say that code A4595 is an accepted procedure code. The 
Plan denied your request. The Plan says the documentation does not support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
We looked at the file and the rules. The record does not contain a valid physician order, proof of delivery, or 
relevant medical records which support medical necessity for the supplies provided in this case. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success.  Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the durable medical equipment billed for date of service June 6, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 6, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the records support multiple procedures. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
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 76641 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 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service October 6, 2022.
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 an office visit. You say that the provider you were authorized with is too far 
to commute to. The Plan denied your request. The Plan says there are providers available in-network and the 
services can be safely done within the area. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 provided on March 26, 2022. 
 
You asked the Plan to pay for procedure code 99221. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as 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, the CPT Code Manual definition of code 99221 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A 
detailed or comprehensive examination; and Medical decision making that is straightforward or of low 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the problem(s) requiring admission are of low severity. Typically, 30 minutes are spent 
at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99221 is not supported in the medical record. Specifically, the file shows that the 
enrollee was admitted as an outpatient on the date of service at issue in this appeal. Code 99221 is an inpatient code. Based on this information, we decided that Medicare rules for coverage of procedure code 99221 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99221 provided on 
March 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 22, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that there is no agreement that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay 
for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 22, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom-made shoes (E1399). 
 
You asked the Plan to pre-approve the custom-made shoes (E1399). You say that you are asking for coverage 
of custom-made shoes due to pressure ulcers on the enrollee's feet. The Plan denied your request. The Plan says 
this item is not a covered benefit for the enrollees condition. 
 
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 the enrollee does not meet criteria for coverage of the requested custom-made shoes as they 
do not wear a shoe that is an integral part of a covered brace. Although orthotics may be appropriate for the 
enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, 
we decided that the Plan does not have to pre-approve custom-made shoes (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on February 3, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing facility visit. You say that you depend on the facility staff to 
verify eligibility and to obtain proper authorization. The Plan denied your request. The Plan says there is no 
authorization on file for the services provided. 
 
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 skilled nursing facility visit provided on 
February 3, 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 a limited oral evaluation (D0140) and intraoral radiographic 
image (D0220) provided on September 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were sent to the dentist, and you would like 
to appeal the denied dental services. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because the limited oral evaluation and the intraoral radiographic image are not 
covered by 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 a limited 
oral evaluation (D0140) and intraoral radiographic image (D0220) provided on September 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), prophylaxis 
(D1110), periapical x-rays (D0220, D0230), and bitewing x-rays (D0274) provided on November 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you saw the same provider, but they had 
changed their address. The Plan denied your request. The Plan says the dental services were received from an 
out-of-network provider and are 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 items or services 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 a comprehensive oral evaluation (D0150), prophylaxis (D1110), periapical x-rays (D0220, D0230), 
and bitewing x-rays (D0274) provided on November 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 11, 2022. 
 
You asked the Plan to pay for the home health services as billed. The Plan denied your request. The Plan says 
the claim has not been billed with the correct admission date. 
 
 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the claim at issue was not billed with an admission 
date in 2022 as required. Based on this information, we find that the Medicare rules for payment of the claim at 
issue have not been met. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from August 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient services provided on July 22, 
2022, to August 4, 2022. 
 
You asked the Plan to waive the copayment for inpatient services. You say that you are disputing the share 
cost. 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 $275 per 
day for days 1 to 5 for inpatient hospital care. This inpatient hospital stay lasted 5 days, resulting in a 
copayment amount of $1,375 ($275 per day for 5 days = $1,375). 
 
You have been asked to pay $275 per day for days 1 to 5 for inpatient services. This item/service 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 
services provided on July 22, 2022, to August 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lab testing to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve lab testing. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says it is important to know which providers are part of the plans network 
because, with limited exceptions, while the enrollee is a member of the plan, they must use network providers 
to get their medical care and services. The only exceptions are emergencies, urgently needed services when the 
network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and 
cases in the plan authorizes use of out-of-network providers. See Chapter 3 (Using the plans coverage for their 
medical services) for more specific information about emergency, out-of-network, and out-of-area coverage. 
 
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 
lab testing to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided from 
September 7, 2022, through September 8, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
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 provided 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 
(A9270) provided from September 7, 2022, through September 8, 2022.  
 Benefits for these items 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental crowns-resin with noble metal (D2722 x 2). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
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 are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental 
crowns-resin with noble metal (D2722 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chiropractic office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a chiropractic office visit. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says requested services can be performed by an in-network 
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 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 chiropractic office visit 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 pay for procedure code J3301 billed for date of service May 9, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed 
services cannot be verified. 
 
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, the CPT Code Manual definition of code J3301 is injection, triamcinolone acetonide, not otherwise 
specified, 10 mg. 
 
 
 The file shows that 4 units of CPT code J3301 were billed. We find that 4 units of CPT code J3301 is not 
supported in the medical record. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
J3301 billed for date of service May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown - porcelain fused to high noble metal 
tooth #13 (D6750). 
 
You asked the Plan to pre-approve the dental services. You say that you are asking for reconsideration to 
approve tooth number 13. You also say that you are very upset why it needs to be once every five years. 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 7, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a retainer crown - porcelain fused to high 
noble metal tooth #13 (D6750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for out-of-network Medicare 
Part B prescription drugs and specialist office visit provided on July 6, 2022. 
 
You asked the Plan to waive the copayment and coinsurance for out-of-network Medicare Part B prescription 
drugs and specialist office visit. You say that you disagree with cost-share. 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 50% 
coinsurance for out-of-network Medicare Part B prescription drugs and a $60 copayment for out-of-network 
physician/practitioner services.  You have been asked to pay a 50% coinsurance for out-of-network Medicare Part B prescription drugs and a 
$60 copayment for specialist office visit. The total allowed amount for the prescription drugs is $9.71. You are 
being asked to pay $4.85 ($9.71 x 50% =$4.85). The total amount you are being asked to pay $64.85 ($60 
+$4.85 = $64.85). This item/service falls within the out-of-network Medicare Part B prescription drugs and 
out-of-network physician/practitioner 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 and coinsurance for out-of-network Medicare Part B prescription drugs and specialist office visit 
provided on July 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an acupuncture visit provided on October 6, 2020, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an acupuncture visit. You say that these services do not require an authorization. 
The Plan denied your request. The Plan says there was no preauthorization by a primary care provider (this is 
different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. 
Therefore, the decision is upheld. 
 
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 acupuncture visit provided on October 6, 2020, 
by an out-of-network (OON) provider.