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

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
June 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the provider relies on the facility staff to 
verify eligibility and to obtain the proper authorization. You also say that the medically necessary service was 
rendered to the enrollee in good faith. The Plan denied your request. The Plan says prior authorization was not 
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 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 subsequent nursing facility care (99309) provided on June 7, 
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 the electrical stimulator supplies (A4595) provided on June 
8, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you would like this claim 
reprocessed and approved for payment based on the medical records. The Plan denied your request. The Plan 
says transcutaneous electric nerve stimulation (TENS) units and garments and supplies for chronic back pain is 
not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the medical records do not feature the ordering provider discussing the ordered equipment with the enrollee. Therefore, we decided that the Plan does not have to pay for the electrical 
stimulator supplies (A4595) provided on June 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits provided on February 10, 
2022, to June 21, 2022. 
 
You asked the Plan to waive the copayment for office visits. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $45 
copayment for Podiatry Services. There were 6 office visits, resulting in a total copayment amount of $270. 
The enrollee is responsibility to pay for $135, which is less than the $270. 
 
You have been asked to pay $45 copayment for each office visit. This item/service falls within the Podiatry 
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 office visits provided on 
February 10, 2022, to June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 the dental 
services on August 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided on May 3, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing facility services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services 
to be provided by an out-of-network provider. 
 
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 skilled nursing facility services provided on May 
3, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist visit provided on June 28, 2022. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you are disputing the share cost. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $40 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $40 copayment for specialist visit. This item/service 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 specialist visit provided on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 03, 2022. 
 
You asked the Plan to pay for the office visit. You say that you have seen this provider for years and claims 
were previously paid. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on August 03, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department evaluation and management 
(E&M) visit and treatment of post-hip arthroplasty dislocation provided on June 27, 2022. 
 
You asked the Plan to pay for emergency E&M visit and surgical service. You say that this code has been 
amended with modifier -54 and should qualify for separate reimbursement. The Plan denied your request. The Plan says the documentation does not indicate that multiple emergency department visits were performed on 
this date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management 
service is provided on the same day to the same patient by the same physician or physicians of the same 
specialty in the same group, only one evaluation and management service may be reported unless for unrelated 
problems. Medicare rules also say that postoperative care should be reported with specified modifiers. 
 
We looked at the file and Medicare rules. Code 99285 is not separately payable because the exact same service 
was already billed for this patient, by the same provider, for the same date of service. Code 27265 has not been 
billed with an appropriate modifier to indicate the service was unrelated during the postoperative period of a 
global procedure. Based on this information, we decided that Medicare rules for coverage of emergency E&M 
visit and surgical service have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department evaluation and management (E&M) visit and treatment of post-hip arthroplasty 
dislocation provided on June 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on July 
26, 2022. 
 
You asked the Plan to pay for the dental services. You say that nowhere in your dental plan does it make such a 
statement. You also say that it clearly states exams are $0 costs to the coverage of the dental plan. 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 October 12, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on July 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 15, 2022, to 
April 25, 2022. 
 
You asked the Plan to pay for the home health services. You say that an NOA was submitted. The Plan denied 
your request. The Plan says the NOA was not submitted with the correct bill type. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We look at the file and the rules. We find that the NOA submitted was not billed with the correct type of bill as 
required. Because a valid NOA was not submitted, the claim at issue is unable to be covered at this time. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the home health services provided from April 15, 2022, to April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care provided on June 6, 2022, to 
July 25, 2022. 
 
You asked the Plan to waive the copayment for wound care. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $195 
copayment for outpatient hospital observation.  
 
You have been asked to pay $195 copayment for each wound care. This item/service falls within the outpatient 
hospital observation benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for wound care provided 
on June 6, 2022, to July 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an excess skin removal surgery (15835, 15836). 
 
You asked the Plan to pre-approve the surgical procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the surgical procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record does not indicate the presence of any functional impairment or intertrigo. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an excess skin removal surgery (15835, 15836).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a leadless pacemaker provided on July 8, 2022. 
 
You asked the Plan to pre-approve the leadless pacemaker. You say that the medical records provided support 
the charges in dispute. The Plan denied your request. The Plan says that there was not a modifier or diagnosis 
code billed with the service in dispute that supports the criteria for coverage have been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 leadless pacemaker. Our reviewer 
says that the leadless pacemaker is considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of atrial fibrillation and symptomatic bradycardia. Recent guidelines 
are consistent with the appropriateness of selecting a leadless, as opposed to a traditional, pacemaker, as the 
leadless system has certain advantages in this setting, particularly with atrial fibrillation, where an atrial lead is 
unnecessary. This selection should be looked upon as being at the discretion of the treating physician. 
Therefore, use of a leadless pacemaker would be considered medically appropriate and reasonable in this 
patients clinical management. 
 
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 leadless pacemaker have been met. Therefore, we decided that the Plan has 
to pre-approve a leadless pacemaker provided on July 8, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210 x4) provided on August 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that due to hardships and being on disability you 
cannot pay the additional bills for the dental work. 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 by other services on July 20, 2022, due to 
dates of service August 15, 2022 and September 2, 2022, processing before the claim for the services at issue. 
Therefore, we decided that the Plan does not have to pay for an extraction, erupted tooth requiring removal of 
bone and/or sectioning of tooth (D7210 x4) provided on August 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided to the enrollee on July 25, 2022. 
 
You asked the Plan to pay for definitive UDT for 22 or more drug classes. You say that the treating physician 
determined this service was medically necessary. The Plan denied your request. The Plan says under Medicare 
rules, the requested number of definitive urine drug classes are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that definitive drug testing is indicated when medically 
necessary. 
 
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 definitive UDT for 22 or more drug classes. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found that the medical 
record sent by the provider shows a definitive UDT panel for multiple drug classes was performed, but does not 
show screening test results which are positive or inconsistent with prescription medications, dosing schedules, 
or history and expected results. The review has determined that the records did not support that the enrollee 
needed 22 or more drug classes tested. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of definitive UDT for 22 or more drug classes have not been met. Therefore, we 
decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug classes 
(G0483) provided to the enrollee on July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and x-rays provided on April 8, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that the enrollee had difficulty being transported. 
You say that the physician assigned to provide care required these services to be provided onsite. You also say 
that these services should be reprocessed and paid. The Plan denied your request. The Plan says prior 
authorization was not 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 provider in this case is not a network provider with the Plan. The ordering provider is not a network provider either. 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 office visit and x-rays provided on April 8, 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 the Vitrectomy Chair (E1399), provided on July 9, 2022, to 
August 5, 2022. 
 
You asked the Plan to pay for the Vitrectomy Chair. You say that this item is medically necessary. The Plan 
denied your request. The Plan says this is a preventative item and not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vitrectomy Chair have not been met. Specifically, this item is considered preventative and not 
medically necessary. Therefore, we decided that the Plan does not have to pay for the Vitrectomy Chair 
(E1399), provided on July 9, 2022, to August 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Odansetron Hcl Tab 8 mg. 
 
You asked the Plan to pre-approve prescription drug. You say that the requested medication requires a Part B 
versus Part D determination. The Plan denied your request. The Plan says the requested medication falls under 
Part D coverage, not Part B coverage. The enrollee is being administered the requested drug with cancer 
chemotherapy treatment that is initiated within 2 hours of the administration of chemotherapy. However, it is 
continued for a period to exceed 48 hours and is not used as a full therapeutic replacement for IV anti-emetic 
drugs that would have been administered at the time of the chemotherapy treatment. 
 
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 Odansetron Hcl Tab 8 mg.