Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 24, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you had to travel twice to see a specialist and 
were told they could not help you. 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 February 24, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
March 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic laboratory services provided on February 22, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for diagnostic laboratory services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be 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. 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 diagnostic laboratory services provided on 
February 22, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral 
nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628). 
 
You asked the Plan to pre-approve an intracept procedure. You say that the requested procedure is medically 
necessary. The Plan denied your request. The Plan says the requested procedure does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has had imaging studies of his back that show arthritis of his lumbar 
spine. On MRI, he has Modic changes from L3 to S1. The request is for RFA of the basivertebral nerves at L3 
and L4. This is considered an experimental/ investigational procedure. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 additional injections of Pepcid over a 3 month period 
for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is being used as supportive care for 
chemotherapy. The Plan denied your request. The Plan says that the request for 20 injections (20 units) exceeds 
the number of injections that would be administered during the requested 3 month duration. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 
these services are not medically reasonable and necessary. 16 additional injections of Pepcid are not FDA-
approved for the enrollees diagnosis as the enrollee is only receiving 4 cycles of chemotherapy each given on 
1 day. The use is not supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. Our physician reviewer found that the enrollee's condition does not meet 
criteria for coverage of these services.  
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 16 additional injections of Pepcid over a 3 month period for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
chest you had on March 17, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you believe this should be covered 
100% because it was related to COVID-19. The Plan denied your request. The Plan says you were charged this 
copayment correctly. The Plan says that because the allowed amount for this service ($90.40) is less than your 
copayment obligation, you are responsible for the full allowed 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 $180 
copayment for advanced imaging services.  
 
You have been asked to pay a $180 copayment for the CT scan. The CT scan falls within the advanced imaging 
services benefit category. The medical records from this service indicate that this CT scan was ordered due to 
emphysema, not due to a diagnosis of COVID-19. 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) scan of the chest you had on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine provided on January 7, 2022. 
 
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not covered 
under Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on January 7, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided on April 30, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the PT services. You say that the office, individual provider, and referring 
provider all participate with Medicare. You also say that the services should be covered. The Plan denied your 
request. The Plan says authorization was not obtained before the services were rendered to the enrollee. 
 
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 provider in this case is not a network provider with the Plan. 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 physical therapy (PT) services provided on April 30, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Ankle foot orthosis (L1971) Foot, heel stabilizer, 
prefabricated, off-the-shelf, (L3170) 
 
You asked the Plan to pay for the orthoses. You say that this claim met all of Medicare's DME LCD coverage 
criteria. The enrollee's primary care physician prescribed this brace within 6 months of the face-to-face visit. 
The Plan denied your request. The Plan says the records provided do not support the billed service. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the orthoses. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that the joint is unstable or that there is joint laxity. There 
is no indication that an AFO is required for stabilization for medical reasons or that there is a potential to 
benefit the enrollee functionally. The requested AFO orthosis is 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 the orthoses have not been met. Therefore, we decided that the Plan does not 
have to pay for Ankle foot orthosis (L1971) Foot, heel stabilizer, prefabricated, off-the-shelf, (L3170)
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from August 17, 2020, to 
August 23, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient level of care provided 
from August 17, 2020, to August 23, 2020, was medically necessary. The Plan denied your request. The Plan 
says that the inpatient level of care provided from August 17, 2020, to August 23, 2020, was not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the clinical documentation in the case file supports that, at the time of inpatient admission, the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 
emergency department and/or observation care) would span two midnights. The enrollee's symptoms, exam 
findings, and imaging results support the enrollee's medically necessary hospital care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from August 17, 2020, to August 23, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services (88341, 88342, 88360 and 88381) 
provided on August 20, 2021. 
 
You asked the Plan to pay for the pathology services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the provider has not billed this claim as 
required by Medicare billing 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. 
 
We looked at the file and Medicare rules. In this case, these services have been billed without a modifier 
indicating that you are requesting payment for the technical and professional component of the rendered 
services. The technical component for these services is not eligible for payment since the enrollee was 
outpatient at the time of service. Therefore, these services must be billed with modifier 26 indicating only the 
professional services are being requested for payment. Based on this information, we decided that Medicare 
rules for coverage of the pathology services have not been met. Therefore, we decided that the Plan does not 
have to pay for the pathology services (88341, 88342, 88360 and 88381) provided on August 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the requested item is necessary 
for your care. The Plan denied your request. The Plan says medical necessity rules for a portable oxygen 
concentrator have not been met. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a portable oxygen concentrator Our 
reviewer says that a portable oxygen concentrator is not medically reasonable and necessary in this case. Our 
physician reviewer found that there is no physician assessment in the case record of your need for a portable 
oxygen concentrator. There is no documentation that oxygen saturation can be maintained greater than 91 
percent with exertion using an oxygen conserving device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for Outpatient hospital services and 
Outpatient diagnostic tests on January 5, 2022, to January 24, 2022. 
 
You asked the Plan to waive the copayments for Outpatient hospital services and Outpatient diagnostic tests. 
You say that you would like to appeal the cost share. The Plan denied your request. The Plan says the 
copayments applied are correct. The services provided on January 5, 2022, and January 24, 2022, were 
incorrectly applied $25 copayments.  However, each date has been adjusted to have the correct $95 copayment 
per the EOC.  The claim for the service provided on January 12, 2022, applied a correct copayment amount of 
$20. 
 
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 $20 
copayment and two $95 copayments for Outpatient hospital services and Outpatient diagnostic tests. The total 
amount owed is $210. 
 You have been asked to pay a $20 copayment and two $95 copayments for Outpatient hospital services and 
Outpatient diagnostic tests. Outpatient hospital services and Outpatient diagnostic tests falls within the 
Outpatient hospital services and 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 copayments for Outpatient hospital services and Outpatient 
diagnostic tests on January 5, 2022, to January 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion drugs billed with code S9347. 
 
You asked the Plan to pay for home infusion drugs billed with code S9347. You say that this is a valid code 
and has been paid in the past. The Plan denied your request. The Plan says this code is not valid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S9347 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9347 is not valid for Medicare purposes. It may be a valid code for other insurance, but not for 
Medicare.  Medicare rules require that a different code be billed for these services. Based on this information, 
we decided that Medicare rules for coverage of home infusion drugs billed with code S9347 have not been met. 
Therefore, we decided that the Plan does not have to pay for home infusion drugs billed with code S9347.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for psychotherapy on October 20, 2021. 
 
You asked the Plan to waive the copayment for psychotherapy. You say that you were told that this provider 
was in-network The Plan denied your request. The Plan says the cost-sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $55 
copayment for each out-of-network Medicare-covered individual or group therapy visit with a psychiatrist. 
Covered services include: Mental health services provided by a statelicensed psychiatrist or doctor, clinical 
psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or other 
Medicare-qualified mental health care professional as allowed under applicable state laws.  
 
 
 
 
 You have been asked to pay a $55 copayment for psychotherapy. Psychotherapy falls within the Outpatient 
mental health 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 psychotherapy on 
October 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper lid blepharoplasty. 
 
You asked the Plan to pre-approve the requested services. You say that the visual field test was failed. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that blepharoplasty services are only covered under 
certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the record indicates that the enrollee has blepharoptosis. The provided record is insufficient 
to determine that the coverage criteria are satisfied. Therefore, the requested service is not recommended. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an upper lid blepharoplasty.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy services (90837) provided on 
January 5, 2022 to January 26, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that the enrollee is a long-time patient of the 
doctor. She suffers from severe mental health disorders. Safety concerns were elevated and would have been 
unethical to terminate care at that time due to the enrollee's need of crisis management. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 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 individual psychotherapy services (90837) 
provided on January 5, 2022 to January 26, 2022 by an out-of-network (OON) provider.