Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits (99213, 99214, 99215), electrocardiogram 
(ECG) tracing (93005), radiologic exams (71046), physical therapy (97161) and medical nutrition therapy 
services (97803, 97802) provided from January 8, 2021, to May 3, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for out-of-network services. You say that you believed these providers were in-
network and you did not know this care would not be covered. You have seen these providers for your care for 
some time before enrolling in this plan. The Plan denied your request. The Plan says out-of-network care is not 
covered by your Plan. The providers in this case are not part of the Plan's network. The requested services were 
not pre-approved or urgent/emergent, and the necessary care could have been received 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 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. No referral was submitted for review, and no medical records were provided to support 
that it was necessary that you continue care with these specific providers. 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 
office visits (99213, 99214, 99215), electrocardiogram (ECG) tracing (93005), radiologic exams (71046), 
physical therapy (97161) and medical nutrition therapy services (97803, 97802) provided from January 8, 
2021, to May 3, 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 wound debridement services you received 
at an outpatient hospital facility on June 24, 2021. 
 
You asked the Plan to waive the copayment for the wound debridement services. You say that you believe the 
copayment for this should only be $40. You stated that this was just a visit to the wound clinic. The Plan denied 
your request. The Plan says you were charged this copayment 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 $325 
copayment for outpatient hospital services (including services in an outpatient clinic).  
 
 You have been asked to pay a $325 copayment for the wound debridement services. The wound clinic where 
you received these services is considered an outpatient hospital clinic. That is why the wound debridement 
services fall within the outpatient hospital services (including services in an outpatient clinic) 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 wound debridement services you received at an outpatient 
hospital facility on June 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the scanning computerized ophthalmic diagnostic imaging 
(SCODI) rendered on March 30, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
 We looked at the file and Medicare rules. The file shows that the services were billed with mismatched 
diagnosis codes. It is not appropriate to bill both bilateral diagnosis and left/right diagnosis codes. Therefore, 
we decided that the Plan does not have to pay for the scanning computerized ophthalmic diagnostic imaging 
(SCODI) rendered on March 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 15, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied procedures are mutually exclusive to already approved and reimbursed procedures paid by the plan.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that the denied codes are not supported by the records in this case. There needs to be a claim submitted with the -59 modifier to show that this was separate and distinct service. The rendering provider failed to provide any medical records that showed the services previously paid for the same date of service were separate from the second billing. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for blood transfusion services provided to the enrollee on April 
30, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the codes billed need to be done on an outpatient form type. 
 
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 the denied codes is: 
 
P9040: 
 
Red blood cells, leukocytes reduced, irradiated, each unit 
 
P9073: 
 
Platelets, pheresis, pathogen-reduced, each unit  
We find that CPT code  is not supported in the medical record. Specifically, the denied codes do not have a 
value on the Professional Physician Fee Schedule. Therefore, the claim type submitted in this case is not valid. 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pay for blood transfusion services provided to the enrollee 
on April 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided April 28, 
2021. 
 
You asked the Plan to pay for the crown. You say that teeth are necessary to eat and speak. The Plan denied 
your request. The Plan says you have exceeded your dental allowance. 
 
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 certain dental 
services up to a $2,000 annual dental allowance.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that you have exceeded 
your annual dental allowance. Therefore, we decided that the Plan does not have to pay for the crown - 
porcelain/ceramic (D2740) provided April 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the standardized assessment from physical shows that you can accomplish 
mobility-related activities of daily living inside the home. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation 
does not support that you have a  mobility deficit that impairs MRADLs in the home and is not ameliorated by 
a walker or cane. The requested scooter exceeds your needs, and will not significantly aid the performance of 
MRADLs in the home.  
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on November 
2, 2020, to December 7, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the services were provided 
with no adequate time frame to obtain authorization. You say the services are medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan 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. 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 subsequent nursing facility care provided on November 2, 
2020, to December 7, 2020, 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 intraoral - periapical first radiographic image (D0220) 
and intraoral - periapical each additional radiographic image (D0230) provided May 20, 2021. 
 
You asked the Plan to pay for the intraoral x-rays. You say that you had a normal dental visit, and it should be 
covered. The Plan denied your request. The Plan says this type of x-ray is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic 
image (D0230) provided May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
December 15, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The 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 out of network physician services provided to the 
enrollee on December 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scans 
provided on February 5, 2021. 
 
You asked the Plan to waive the copayment for the CT scans. You say that your diagnosis was incorrect in your 
chart. 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 $110 
copayment for radiological diagnostic services.  
 
You have been asked to pay a $110 copayment for each of the CT scans. CT scans 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 the computed tomography (CT) scans provided on February 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drainable ostomy pouches you 
received from June 16, 2021, to August 17, 2021. 
 
You asked the Plan to waive the coinsurance for the ostomy pouches. You say that these pouches should not be 
considered durable medical equipment because they are disposable. The Plan denied your request. The Plan 
says you were charged this coinsurance 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 prosthetics and related supplies.  
 
You have been asked to pay 20% coinsurance for the ostomy pouches. We agree that the pouches you received 
are not durable.  However, the pouches do fall within the prosthetics and related supplies category.  For 
example, your Evidence of Coverage even states that supplies related to ostomy care fall under this benefit.  
The prosthetics and supplies coinsurance is the same as the durable medical equipment coinsurance. 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 the drainable ostomy pouches 
you received from June 16, 2021, to August 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds criteria for LTACH 
admission. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute 
care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation provided indicating medical necessity for admission to 
an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) coded 70450 provided on 
June 15, 2021. 
 
You asked the Plan to pay for the computed tomography (CT). You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are 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 CPT code. In this case, we have confirmed that code 70450 
for the computed tomography (CT) is a column II code to column I code 70496. 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 the computed tomography (CT) 
coded 70450 provided on June 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from April 24, 2021, to April 29, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you cannot afford this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $350 copayment for each hospital stay. You have been asked to pay a $350 copayment for the inpatient hospital services. 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 services you received from April 24, 2021, to April 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testosterone Gel. 
 
You asked the Plan to pre-approve self-administered drug. You say that the enrollee's condition gets worse 
when he does not have this drug. The Plan denied your request. The Plan says the denial of authorization for 
this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the 
enrollee's Medicare Part D prescription drug benefits. 
 
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 Testosterone Gel.  
 
Benefits for self-administered drug 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee continues to receive acute care services and these have not been 
denied. The medical record does not indicate that the enrollee requires services that he is not currently 
receiving but that would be available at the LTACH facility.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray exam, chest; 2 views (71046) 
rendered on July 8, 2021. 
 
You asked the Plan to waive the copayment for an x-ray exam, chest; 2 views. You say that you do not think 
you should have to pay the copayment since you pay the monthly premium. The Plan denied your request. The 
Plan says you were charged the correct copayment 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 $35 
copayment for each basic imaging service, including x-rays.  
 
You have been asked to pay $32.54, which is less than the $35 copayment for an x-ray exam, chest; 2 views. 
X-ray exams, chest; 2 views 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 an x-ray exam, chest; 2 views 
(71046) rendered on July 8, 2021.