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

 
We decided that the Plan does not have to waive the copayment for an office visit provided on October 27, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $45 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
 You have been asked to pay a $45 copayment for an office visit. 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 October 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the epidurography with radiological supervision and 
interpretation rendered on May 5, 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 are not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the records do not support that the procedure was separate and distinct from the anesthetic injection with imaging guidance (62323). Based on this information, we decided that Medicare rules for 
coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not 
have to pay for the epidurography with radiological supervision and interpretation rendered on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transitional care management services provided on 
August 24, 2021, by an OON provider. 
 
You asked the Plan to pay for the transitional care management services. You say that the providers rely on 
facility staff to verify eligibility and obtain authorization. The Plan denied your request. The Plan says the 
services were provided out-of-network and were not approved in advance. 
 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 transitional care management services 
provided on August 24, 2021, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from December 1, 2020, to December 3, 2020. 
 
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 provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the documentation in the case file do 
not support shortness of breath or trouble breathing while lying flat in this enrollee. 
 
We looked at this coder's review, the file, and Medicare rules. 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 skilled nursing facility (SNF) services provided to the enrollee from December 1, 2020, to 
December 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine eye exam provided on December 20, 2021. 
 
You asked the Plan to pay for a routine eye exam. The Plan denied your request. The Plan says vision care 
covered services include outpatient physician services for the diagnosis and treatment of diseases and injuries 
of the eye, including treatment for age-related macular degeneration. Original Medicare doesnt cover routine 
eye exams (eye refractions) for eyeglasses/contacts. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services. 
 
The services you asked the Plan to pay for are considered routine vision services. Therefore, we decided that 
the Plan does not have to pay for a routine eye exam provided on December 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services. 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says this is to be performed by a nurse practitioner. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy, as long as it is performed by a qualified physical therapist. 
 
These services are not going to be provided by a qualified physical therapist. 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 pre-approve physical therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the composite/resin fillings provided on October 15, 2021. 
 
You asked the Plan to pay for the resin fillings. You say that fillings are listed with a $0 copayment in your 
contract, and you expected the cost to you for your three fillings to be $0. Instead, you are being charged $30 for each tooth. You feel the compound that the dentist uses should not matter in the cost to you, and you had no 
control over the materials used to fill your teeth. The Plan denied your request. The Plan says while fillings are 
a covered service, it is considered not necessary to have fillings made from the more expensive resin/composite 
material (white fillings) for back teeth. This service is available to you as an optional service; however, because 
the service is not necessary, an additional cost to you is required. The Plan pays the full allowed amount for the 
equivalent amalgam/silver filling, and you pay the difference between the covered cost of the amalgam and the 
additional cost of the resin/composite. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan states that if you 
select a more expensive service than is customarily provided, the Plan may make an allowance for certain 
services based on the fee for the customarily provided service. If you receive composite (white) restorations for 
the back teeth, the Plan will pay only the amount that it would have paid to restore the tooth with amalgam 
(silver) fillings. You are responsible for the difference in cost. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the extra cost of composite fillings is 
not covered when these services are provided for posterior teeth. In this case, the documentation shows that you 
received three fillings for molars on October 15, 2021. The provider billed the Plan $174 for each of the 
fillings. The Plans allowed cost for the composite fillings is $110, and the allowed cost for the equivalent 
silver filling is $80. The Plan has paid the full $80 cost of the silver filling, and you are responsible for the 
difference between this paid amount and the Plans price for the composite restorations ($110 - $80 = $30.) 
This means you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we 
decided that the Plan does not have to pay the remaining for the composite/resin fillings provided on October 
15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of the left breast implant. 
 
You asked the Plan to pre-approve removal of the left breast implant. You say that the requested removal of the 
left breast implant is medically necessary. The Plan denied your request. The Plan says the requested removal 
of the left breast implant is 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 removal of the left breast implant. Our 
reviewer says that the requested removal of the left breast implant is not medically necessary. Our physician 
reviewer found the record indicates that the enrollee previously received cosmetic breast implants. The record 
indicates that the right one is ruptured. The record does not indicate that the left implant has ruptured or the 
presence of painful contractures.  The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 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 removal of the left breast implant have not been met. Therefore, we decided that 
the Plan does not have to pre-approve removal of the left breast implant.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0480) provided February 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (G0480) provided February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on October 29, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain an 
authorization and the service was rendered in good faith. The Plan denied your request. The Plan says the 
rendering provider is an out-of-network provider and there was no approved authorization. Also, the service 
rendered 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 a home health visit provided on October 29, 2021, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tramadol HCl. 
 
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 self-administered drugs are not covered. 
 
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 Tramadol HCl.  
 
Benefits for these services 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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
provided documentation is insufficient to support the Plans denial. The Plan states that SNF coverage is not 
medically necessary but are referencing medical records that were not submitted for review. As such, the 
provided documentation is insufficient to support the denial and we must find in your favor. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
   
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound (76775) provided on 
December 1, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $100 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $100 copayment for an ultrasound. Ultrasounds 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 ultrasound (76775) provided on December 1, 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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 record indicates that the enrollee remains critically ill. 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. 
The elements of the coverage rules are not satisfied. 
 
 
 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG) recording rendered on June 
24, 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 procedure code 95816 is not supported. 
 
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 95816 is electroencephalogram (EEG); including 
recording awake and drowsy.  
We find that CPT code 95816 is not supported in the medical record. Specifically, there is no documentation of 
an interpretation and report for the date of service at issue. 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 pay for the electroencephalogram (EEG) recording rendered on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound debridement of the muscle and/or fascia (11043) 
provided on September 29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for wound debridement of the muscle and/or fascia. You say that the treatment 
rendered to the patient was medically necessary per the physician that provided the service. The Plan denied 
your request. The Plan says this provider is a non-contracted provider who performed services to the member 
without prior authorization from the Plan. The Plan also says that this provider has been notified previously 
that they must obtain prior authorization to provide services to their members. 
 
 
 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 wound debridement of the muscle and/or fascia 
(11043) provided on September 29, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing services (D4341) 
provided on November 4, 2021. 
 
You asked the Plan to pay for periodontal scaling and root planing. You say that you have seen this dentist for 
years and know you have $1,200 in dental benefits, and you do not understand why you are not being 
reimbursed for this care. The Plan denied your request. The Plan says the provider in this case has chosen to 
opt-out of Original Medicare, and therefore these services are not eligible for reimbursement. 
 
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. Your contract with the Plan 
states that you may see any licensed dental provider who accepts Medicare patients in the United States and has 
not opted out of Original Medicare. If you use a provider that has opted out of Medicare, you will not receive 
reimbursement. 

Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from 
providers who have opted out of Original Medicare are not among those covered under this benefit. 
Documentation shows that the provider in this case does not participate in Medicare. Therefore, we decided 
that the Plan does not have to pay for periodontal scaling and root planing services (D4341) provided on 
November 4, 2021.