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

We decided that the Plan does not have to pay for the office visit provided on April 16, 2021 by a non-
participating provider. 
 
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 were rendered by a non-participating provider without prior authorization. 
 
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 office visit provided on April 16, 2021 by a 
non-participating provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging of the lumbar spine; without contrast (74178) and the magnetic resonance imaging of any joint of the lower extremity; without contrast (73721) rendered by the out-of-network (OON) provider on June 2, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging of the lumbar spine; without contrast (74178) and the magnetic resonance imaging of any joint of the lower extremity; without contrast (73721) rendered by the out-of-network (OON) provider on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99212) provided on June 2, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you did not see the doctor and 
believe you should not be charged for these services. The Plan denied your request. The Plan says the 
copayment has processed correctly in this case. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for Medicare-covered specialist services.  
 
You have been asked to pay a $40 copayment for the office visit. This service falls within the Medicare-
covered specialist services benefit category. We have confirmed through the medical records that you did 
receive these services in a specialist's office. 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 office 
visit (99212) provided on June 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the advanced life support (ALS) disposable supplies (A0398 
x 6), ALS specialized service disposable supplies (A0394), ambulance oxygen and supplies (A0422 x 2), and 
BLS routine disposable supplies (A0382) provided on June 17, 2021. 
 
You asked the Plan to pay for the ambulance supplies. You say that you fell and hit your head. You say that 
your neighbor found you 3 hours later. You also say that these services should be covered. The Plan denied 
your request. The Plan says that the rules for coverage of ambulance supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services which include but are not 
limited to oxygen, drugs, extra attendants, supplies, EKG, and night differential are no longer paid separately 
for ambulance services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance supplies have not been met. Specifically, ambulance supplies are not separately 
payable for ambulance services. The record shows that the Plan paid for the ambulance transport and ground 
mileage. Therefore, we decided that the Plan does not have to pay for the advanced life support (ALS) 
disposable supplies (A0398 x 6), ALS specialized service disposable supplies (A0394), ambulance oxygen and 
supplies (A0422 x 2), and BLS routine disposable supplies (A0382) provided on June 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from February 25, 2021, 
through March 17, 2021. 
 
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
physical therapy services. We found no exception that would require the Plan to pay for these services. 
Therefore, we decided that the Plan does not have to pay for physical therapy services provided from  
February 25, 2021, through March 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (88377, 88360) rendered by the out-
of-network (OON) provider on June 3, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (88377, 88360) rendered by the out-of-network (OON) 
provider on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites (D2330 x2) provided on May 
11, 2021. 
 
You asked the Plan to pay for the resin-based composites. You say that you were advised that the Plan would 
cover two fillings per year. You also say that you limited treatment to the four lower teeth which were most in 
danger of breakage and planned to cover the cost of two of these procedures yourself. The Plan denied your 
request. The Plan says benefits for this service have been satisfied and the frequency limitation has been 
exceeded. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, restorations are limited to two 
procedure codes per calendar year. The record shows that you received four resin-based composites (D2330 
x4), two of which were covered at the in-network benefit rate as a one-time exception, and your restorations 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the two resin-based 
composites (D2330 x2) provided on May 11, 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 for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and 
is currently unstable for transfer to an LTACH. 
 
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. The enrollee 
was admitted with acute hypoxic and hypercapnic respiratory failure. The enrollee continues to have low 
oxygen saturation. 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 she is not currently receiving but that 
would be available at the LTACH facility. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on May 
2, 2020. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you did not get a bill for other 
inpatient services you received later in the year, and you feel these services should be covered in full. The Plan 
denied your request. The Plan says each time you are admitted to an acute care hospital, you pay $200. You 
will not pay more than $400 for covered inpatient hospital services in a calendar year, but at the time of this 
admission you had not met this $400 maximum. 
 
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 $200 
copayment for each time you are admitted to an acute care hospital.  
 
You will not pay more than $400 per calendar year for covered inpatient care. 
 
You have been asked to pay a $200 copayment for the inpatient admission. The record indicates that at the time 
of this admission, you had not yet met your $400 annual maximum for inpatient services. 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 inpatient hospital care provided on May 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for sleeves and gauntlets (A4467, A9270) provided on April 29 
and June 16, 2021. 
 
You asked the Plan to pay for sleeves and gauntlets. You say that multiple representatives of the Plan have told 
you that the supplies at issue would be covered at 80%. The Plan denied your request. The Plan says rules for 
payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that elastic or other fabric support garments with or 
without stays or panels do not meet the statutory definition of a brace. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of sleeves and gauntlets have not been met. Specifically, the items at issue are not a covered benefit 
under Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for sleeves and gauntlets 
(A4467, A9270) provided on April 29 and June 16, 2021.  
 
Your complaint about receiving erroneous or incomplete information about your benefits from representatives 
of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 20, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from October 20, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care from October 20, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment beyond the date in question of October 20, 2021, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond October 20, 2021, as she was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from October 20, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 20, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), complete 
series of intraoral x-rays (D0210), and prophylaxis (D1110) provided on June 17, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay more for the comprehensive oral evaluation, complete series of intraoral x-rays, and 
prophylaxis. You say that you called to see if you could go to this treating dentist and were told yes. The Plan 
denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that 
when you contacted the Plan inquiring about in-network providers, the provider who rendered these services 
was not discussed on the call. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for a 50% 
coinsurance plus the difference between the billed amount and allowed amount because the services were 
received OON. Therefore, we decided that the Plan does not have to pay more for the comprehensive oral 
evaluation (D0150), complete series of intraoral x-rays (D0210), and prophylaxis (D1110) provided on June 
17, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99601) provided on May 7, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not
payable.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee
Schedule indicates that the code in question is not valid for Medicare purposes.
We looked at the file and Medicare rules. Code 99601 is assigned a status indicator of "I" under the Physician
Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for
reporting of, and payment for, these services. 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 the
services (99601) provided on May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider 
on May 7, 2021, and June 22, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on 
May 7, 2021, and June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2750) and core build up (D2950) provided on June 28, 2021.
You asked the Plan to pay for the dental services. You say that the dentist verified that the services would be covered. You say that you were advised your responsibility would owe $353. You say that the services should be covered as surgery to remove your broken tooth. The Plan denied your request. The Plan says the crown and core build up are not listed as covered services.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the crown and core build up are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown (D2750) and core build up (D2950) provided on June 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) with accessory provided on April 22, 2021.
You asked the Plan to pay for pneumatic compression device. You say that the enrollee's physician has prescribed the use of a pneumatic compression device to prevent the formation of blood clots. The Plan denied your request. The Plan says the denial of payment for these items is correct, because a pneumatic compression device coded as E0675 is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device coded as E0675 is not covered by Medicare, and if a base pneumatic compression device is not covered then related accessories will also be denied.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) with accessory provided on April 22, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to waive the copayment for the cystoscopy procedure you received at an outpatient hospital facility on November 16, 2020.
You asked the Plan to waive the copayment for the cystoscopy procedure.. You say that you were advised you hit your out-of-pocket maximum in September before these services. The Plan denied your request. The Plan says that you were charged this copayment 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 says that the most you will have to pay out-of-pocket for in-network services in 2020 is $4,250. If you reach this out-of-pocket maximum, you will not have to pay any out-of-pocket costs for the rest of the year for in-network services.
We looked at your contract with the Plan as well as the case file that the Plan submitted to us for review. The burden is on the Plan to show why their assessment of a $200 copayment for this procedure was correct. They have failed to do so. The case file that the Plan submitted to us did not address your allegation of meeting your out-of-pocket maximum in any way. The Plan has failed to provide any documentation regarding how much of your out-of-pocket maximum had been satisfied as of the date of service in question. In fact, the only Explanation of Benefits that the Plan provided to us in their case file submission explicitly stated that you had satisfied your out-of-pocket maximum. Because of the Plan's failure to provide documentation proving that you had not yet met your out-of-pocket maximum at the time of these services, we find that the assessment of a copayment was inappropriate. Therefore, we decided that the Plan has to waive the copayment for the cystoscopy procedure you received at an outpatient hospital facility on November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says this procedure is considered 
experimental/investigational. 
 
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 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 Intracept procedure is experimental. More research is needed to show safety and 
efficacy. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.