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

 
We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat RFA is covered when specific criteria are 
met. 
 
 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of chronic 
low back pain secondary to lumbar spondyloarthropathy and facet arthritis. She has been treated with medical 
therapy, including Cymbalta, and has had lumbar facet injections that provided 90 percent pain relief for one 
month. The records provided states she had excellent relief for a month following facet injections.  The records 
do not show how the patient responded to previous RFA. The records do not show at least 50 percent 
improvement in pain for six months or 50 percent consistent improvement in activities of daily living. The 
criteria for repeat RFA are not met and the services are therefore not medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat radiofrequency ablation (RFA).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 21, 
2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with having to have 
the procedures done on separate days with separate charges. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct 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 $50 
copayment for ultrasounds. 
 
You have been asked to pay a $50 copayment for an ultrasound. An ultrasound falls 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 ultrasound provided on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered item, self-administered drug (A9270) 
provided September 9, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that after spending three months dealing 
with cancer and radiation, you are not ready to take more time to deal with a Walgreens $57.09 refill. The Plan 
denied your request. The Plan says this item is not covered by Medicare or the 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 non-covered item, self-
administered drug (A9270) provided September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee scooter (E0118) provided on October 6, 2021. 
 
You asked the Plan to pay for the knee scooter. You say that the item is medically necessary. The Plan denied 
your request. The Plan says you obtained this item through a provider who is not enrolled in Medicare. 
 
  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the knee scooter (E0118) provided on 
October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist visits provided on May 27, 
2021, and June 21, 2021. 
 
You asked the Plan to waive the copayments for specialist visits. You say that you did not request the 
appointments so you should not be responsible for the charges. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct 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 $40 
copayment for specialist services.  
 
You had specialists visits on May 27, 2021, and June 21, 2021. Therefore, you are responsible to pay a $40 
copayment per each visit. The total amount you owe is: $80.  You have been asked to pay the total copayment amount of $80 for specialist visits. Specialist visits fall within 
the physician/practitioner services, including doctor's office visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayments for specialist visits provided on May 27, 2021, and June 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency transport ambulance service 
(A0427) rendered on October 7, 2021. 
 
You asked the Plan to waive the copayment for emergency transport ambulance service. You say that you 
asked the provider where you were if you could drive yourself and you were told no due to the chest pains you 
had been having. The Plan denied your request. The Plan says you were 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 $250 
copayment for each one-way Medicare-covered ground trip.  
 
 You have been asked to pay a $250 copayment for emergency transport ambulance service. Emergency 
transport ambulance 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 emergency transport ambulance service (A0427) rendered on October 7, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services 
provided from August 11, 2021, to September 30, 2021. 
 
You asked the Plan to waive the copayment for the SNF services. You say that you were not informed of any 
charges for rehab. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $0 per 
day for days 1-20 and $184 per day for days 21-100 for each benefit period. 
 
 The file shows that you were in the skilled nursing facility from August 11, 2021, to September 30, 2021. 
There is no charge for the first 20 days. You have been asked to pay $184 per day after day 20 for the SNF 
services. Please note that during this stay, you met your maximum out-of-pocket expenses (MOOP) for the 
year. The file shows that as of this time, your remaining amount to reach your MOOP was $4,503.66, which 
matches the total amount charged for the SNF services. The SNF services fall within the Skilled Nursing 
Facility (SNF) 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 skilled nursing 
facility (SNF) services provided from August 11, 2021, to September 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EGD provided on September 24, 2021. 
 
You asked the Plan to waive the copayment for an EGD. You say that you have only ever paid $125 for this 
service in the past and disagree with the charges. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct 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 $195 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. 
 
You received an EGD at an outpatient hospital facility on September 24, 2021. An EGD is considered an 
outpatient surgical procedure. Therefore, you are responsible to pay the $195 copayment.   You have been asked to pay a $195 copayment for an EGD. An EGD falls within the outpatient surgery and 
other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 EGD provided on September 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulicity injector pen. 
 
You asked the Plan to pre-approve self-administered drug. You say that the enrollee has been established on 
medication since 2017. 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 Trulicity injector pen.  
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoride application, excluding varnish (D1208), and 
periodontal maintenance (D4910) provided on October 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that your periodontal treatment requires a fourth 
cleaning every year. You say that your town does not treat their water with fluoride. You also say that these 
services should be covered. The Plan denied your request. The Plan says fluoride application is covered 2 times 
per plan year. The Plan says that periodontal maintenance is covered 3 times per plan year. The Plan also says 
that these frequency limits have been exceeded. 
 
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 and the services are listed as covered, 
the frequency limits have been exceeded. The record shows that the Plan paid for fluoride application that you 
received on February 18, 2021, and April 1, 2021. The record also shows that the Plan paid for periodontal 
maintenance that you received on February 18, 2021, April 1, 2021, and July 2, 2021. Therefore, we decided 
that the Plan does not have to pay for the fluoride application, excluding varnish (D1208), and periodontal 
maintenance (D4910) provided on October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit (99214) provided on January 4, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit. You say that prior authorization is not required for an 
office visit. The Plan denied your request. The Plan says the member does not have out of network benefits and 
the servicing provider is not a participating provider with the Plan. The Plan also says that these were 
unauthorized 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 a specialist office visit (99214) provided on 
January 4, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 21, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that prior authorization is not required for an office visit 
and the claim should be paid. The Plan denied your request. The Plan says the rendering provider is an out-of-
network provider and the services provided 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 an office visit provided on May 21, 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says admission to a long-term acute care hospital (LTACH) for the enrollee. 
 
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 appears to be improving and requires only short-term additional acute 
care hospital services that can safely completed at the current facility. The enrollee does not require services at 
the LTACH that are not already available at the current facility. Transfer to LTACH is not medically necessary 
as it would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment 
has completed. 
 
 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 
17, 2021 to May 19, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the non-contracted provider had not submitted 
the RAP claim and was submitting the RAP claim while they were submitted this appeal. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the records 
submitted suggest that the RAP for these services was not submitted within 5 days of the start date.. Therefore, 
we decided that the Plan does not have to pay for the home health services provided to the enrollee from May 
17, 2021 to May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D4263) and guided tissue 
regeneration (D4267) provided on September 24, 2021. 
 
You asked the Plan to pay for a bone replacement graft and guided tissue regeneration. You say that you had a 
previous root canal and crown. The tooth fell out; however, the root was still intact. The dentist had to cut the 
gum to remove the root, and sutures were placed in the gum. You believe that since this was dental surgery, the 
services rendered should be payable by the Plan under the surgery benefit. The Plan denied your request. The 
Plan says the requested services are not a covered benefit with your 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 bone 
replacement graft (D4263) and guided tissue regeneration (D4267) provided on September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the spinal cord stimulator trial. 
 
You asked the Plan to pay for the spinal cord stimulator trial. You say that you would like reconsideration 
because this trial is medically necessary. The Plan denied your request. The Plan says the record does not 
support that the member has a covered indication, has a plan for spinal cord stimulation or has a favorable 
mental health evaluation. The Plan must follow Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless all of the 
conditions listed in the Medicare rules section have been met. 
 
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 pay for the spinal stimulator trial. Our reviewer says 
that the member does not meet Medicare criteria for coverage of the spinal cord stimulator trial. Our physician 
reviewer found a psychiatric evaluation has not been submitted and more information is needed to determine if 
criteria have been met. 
 
We looked at this physicians review, the file and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the spinal cord stimulator trial have not been met. Therefore, we decided that 
the Plan does not have to pay for the spinal cord stimulator trial.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation (99443) provided on May 11, 2021. 
 
You asked the Plan to pay for the telephone evaluation (99443). You say that the attached medical records 
should be reviewed, and the claim reconsidered for payment. The Plan denied your request. The Plan says the 
provider did not bill as required by Medicare coding regulations. 
 
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 99443 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 21-30 minutes of medical discussion.  We find that CPT code 99443 is not supported in the medical record. Specifically, CPT code 99443 cannot be 
billed within 7 days of a related evaluation and management service. Based on this information, we decided 
that Medicare rules for coverage of the telephone evaluation (99443) have not been met. Therefore, we decided 
that the Plan does not have to pay for the telephone evaluation (99443) provided on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for eyeglasses provided on August 24, 2021. 
 
You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says the 
provider is not a Plan vision network of providers. 
 Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services when provided by a network optical provider. 
 
We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by a network 
optical provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have 
not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on 
August 24, 2021.