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

 
We decided that the Plan does not have to pay for an office visit provided on January 28, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim and that the services provided were medically necessary. The Plan denied your request. The Plan 
says the provider is out-of-network and it was determined these services were 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 January 28, 2022 by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the item is medically necessary. The Plan denied your 
request. The Plan says you do not use insulin with at least three daily injections and require frequent self-
adjustment of insulin dosage based on the blood glucose testing results. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous 
glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 7, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and 
approved for payment based on medical necessity of the services provided. The Plan denied your request. The 
Plan says this claim has been billed incorrectly based on 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. 
 
In this case, the CPT Code Manual definition of code 33340 is percutaneous transcatheter closure of the left 
atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), 
left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and 
interpretation 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient hospital services have not been met. Specifically, code 33340 has a Payment Status 
Indicator of C meaning that it is an Inpatient Only Procedure. Payment cannot be made for this service 
performed as an outpatient procedure. Furthermore, the entire claim is denying based on an OCE edit. Based on 
the OCE, all claim line items that have been billed on this claim will be denied because they are services being 
billed on an outpatient claim form concurrently with a code that has a Payment Status Indicator of C. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on December 7, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $325 copayment for a diagnostic colonoscopy performed 
on November 17, 2021. 
 
You asked the Plan to waive the $325 copayment a diagnostic colonoscopy. You say that you would like 
reconsideration for the $325 charge to be removed because polyp removal is an integral part of a colonoscopy. 
You also say that the Plan may not impose cost sharing with respect to a polyp removal during a colonoscopy 
performed as a screening procedure. The Plan denied your request. The Plan says that the $325 copayment for 
outpatient surgery has been processed correctly. Per your EOC, a screening colonoscopy can become 
diagnostic in the same visit.  
 
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.   
You have been asked to pay a $325 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls 
within the outpatient hospital 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 $325 copayment 
for a diagnostic colonoscopy performed on November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 test provided on January 5, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for COVID-19 test. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says it was determined that you purchased an at-home 
COVID-19 test on January 5, 2022. Per the plan guidelines, you are covered for the purchase of At-home 
COVID tests effective February 1, 2022. 
 
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 COVID-19 test provided on January 5, 2022 by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Rybelsus tablet. 
 
You asked the Plan to pre-approve Rybelsus. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Rybelsus 
tablet.  
 
Benefits for Rybelsus 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities (97530) provided on November 10, 
2021. 
 You asked the Plan to pay for therapeutic activities. You say that these services were medically necessary and 
were billed correctly. The Plan denied your request. The Plan says these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the therapeutic exercises are not supported as billed by the medical record. Specifically, the 
documentation shows that this claim was billed by a Nurse Practitioner but the therapy services at issue were 
rendered by a Certified Occupational Therapy Assistant. There is no indication that the Nurse Practitioner was 
present on site while the therapy services were being rendered. The incident-to requirements have not been met 
in this case. Based on this information, we decided that Medicare rules for coverage of therapeutic activities 
have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities (97530) 
provided on November 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7210 x 2) provided on January 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were advised in November 2021 your plan 
covered 80% for cleaning, x-rays and extractions. You say that the provider was in network. You also say that 
you have a limited income. The Plan denied your request. The Plan says extractions are not covered. 
 
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 extractions are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extractions (D7210 
x 2) provided on January 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on November 2, 
2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that you feel you should not be 
charged. You say that this was not an office visit, and you just asked the doctor a question. The Plan denied 
your request. The Plan says you have been 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 $20 in-
network copayment for medical care or surgery services in a specialty physician's office.  
 
 
 
 
 You have been asked to pay a $20 copayment for an office visit. The office visit falls 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 copayment for an office visit provided on November 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for x-ray and methylprednisolone injection 
provided on October 6, 2021. 
 
You asked the Plan to waive the cost share for x-ray and methylprednisolone injection. You say that you paid 
your copayment, so any outstanding charges are not your responsibility. The Plan denied your request. The 
Plan says cost share 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 20% 
coinsurance for each in-network Medicare-covered Part B drug and $15 copayment for each in-network 
Medicare-covered standard x-ray service.   
You have been asked to pay $17.22, for the x-ray and methylprednisolone injection. 
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
October 6, 2022 x-ray $32.76 $15 $15 
October 6, 2022 Methylprednisolone 
injection 
$11.10 20% $2.22 
TOTAL:    $17.22 
 
The x-ray falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category and methylprednisolone injection falls within the Medicare Part B Prescription Drugs benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the cost share for x-ray and methylprednisolone injection provided 
on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory work provided on January 5, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the service was 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 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 service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the laboratory work provided on January 5, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 29, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you do not need a primary care physician referral 
based on your contract. 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 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 office visit was urgent or emergent. Therefore, we decided 
that the Plan does not have to pay for the office visit provided on November 29, 2021, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 24, 2020, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the claim reprocessed and 
paid at the Medicare allowed rate. The Plan denied your request. The Plan says the rendering and referring 
providers are both OON providers and the service rendered was not pre-authorized. 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 24, 
2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visit services provided on January 5, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for rest home visit services. You say that you would like to request reconsideration 
for payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were 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 rest home visit services provided on January 5, 
2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 5 to August 
15, 2021. 
 You asked the Plan to pay for inpatient hospital services. You say that the medical record clearly supports the 
provided clinical diagnosis. The Plan denied your request. The Plan says rules for payment on the basis of 
DRG 659 have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, J96.01, defined as "Acute 
respiratory failure with hypoxia." 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 inpatient 
hospital services. Our reviewer says that the available medical records do not support DRG 659 and diagnosis 
code J96.01. Our physician reviewer found that the diagnosis code for Acute respiratory failure with hypoxia is 
not supported by the hospital record.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 5 to August 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair of a domiciliary or rest home visit provided on 
December 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the repair of a domiciliary or rest home visit. You say that the nursing home is 
responsible to obtain prior authorization for their patients, which should cover medical treatments by the 
provider. The Plan denied your request. The Plan says this provider is out-of-network with the Plan, and 
authorization was not obtained prior to the 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 repair of a domiciliary or rest home visit 
provided on December 8, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LINX procedure. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has gastroesophageal 
reflux but his DeMeester scores support that the severity of the reflux varies daily. While some symptoms 
correlate with acid reflux events, others do not. The records do not support that the LINX procedure is 
reasonable and medically necessary for the enrollee in lieu of conventional management strategies. 
 
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 a LINX procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids, digital, binaural, behind the ear (V5261) 
provided November 4, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that your provider told you that your insurance would 
partially cover your hearing aids. The Plan denied your request. The Plan says this service is not covered under 
your benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these 
types of items and services. Therefore, we decided that the Plan does not have to pay for the hearing aids, 
digital, binaural, behind the ear (V5261) provided November 4, 2021.