Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy, implanted pump pain management 
infusion provided on May 21, 2022, to June 17, 2022. 
 
You asked the Plan to pay for home infusion therapy, implanted pump pain management infusion. You say that 
you are appealing the claim payment denial. 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 home infusion therapy, 
implanted pump pain management infusion provided on May 21, 2022, to June 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the heart provided on 
August 15, 2022. 
 
You asked the Plan to pay for the CT scan. You say that the CT scan was medically necessary. The Plan denied 
your request. The Plan says Medicare is the secondary carrier. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
  The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has attempted to 
instruct the provider to submit this claim to your primary insurance carrier. As the secondary insurer, the Plan 
cannot be held responsible for the CT scan until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan of the heart 
provided on August 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203), x-ray exam of the cervical spine 
(72040), and the x-ray exam of the lumbar spine (72100) provided on September 12, 2022. 
 
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 these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99203), x-ray exam of the cervical spine (72040), and the 
x-ray exam of the lumbar spine (72100) provided on September 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 26, 
2022, to March 27, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that you were experiencing a low blood 
sugar, and ate two glucose tabs, but after 30 minutes you were not getting better. You also say that you were 
taken by ambulance to the hospital, and were diagnosed with a low blood sugar and probable cardiac episode. 
The Plan denied your request. The Plan says the requested service is not medically necessary, as there is no 
expectation of requiring a two midnight stay for slurred speech related to hypoglycemia that has resolved. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found you presented to the emergency department with report of hypoglycemia 
and associated slurred speech. You had taken glucose tablets and symptoms resolved prior to the emergency 
department workup. Our reviewer found no additional hypoglycemia episodes or slurred speech occurred 
during the emergency department workup and treatment. Vitals were stable. Workup revealed no evidence of 
cerebral vascular accident. You were admitted for observation but for no other treatment. Our physician 
reviewer also found that there was no documentation suggesting the enrollee warranted hospital services that 
was expected to cross 2 midnights. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from March 26, 2022, to March 27, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676), provided on 
August 31, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676), provided on August 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance service provided on July 28, 
2022. 
 
You asked the Plan to waive the copayment for ambulance service. 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 a $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for ambulance service. This item/service falls within the 
ambulance 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 ambulance service 
provided on July 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on September 30, 
2022. 
 
You asked the Plan to waive the copayment for a colonoscopy. 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 a $250 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $250 copayment for a colonoscopy. 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 a colonoscopy 
provided on September 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for sacroiliac (SI) joint 
(64625). 
 
You asked the Plan to pre-approve the RFA. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the requested service 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 the RFA. Our reviewer says that the 
requested RFA is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested service is considered experimental and investigational due to the wide variation in 
effectiveness reported in the literature. Therefore, the reviewer found that the requested RFA is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (RFA) for sacroiliac (SI) joint (64625).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the 
brain. 
 
You asked the Plan to pre-approve the PET scan. You say that the PET scan is necessary to determine the 
enrollee's memory loss. The Plan denied your request. The Plan says the medical records provided do not 
indicate that the enrollee meets the diagnostic criteria of both AD and FTD. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 PET scan. Our reviewer says that 
the PET scan of the brain is not medically necessary Our physician reviewer found that the enrollee is noted to 
have dementia. There is concern for a vascular process versus AD. There was no mention of FTD in the 
records. As Medicare only covers this service to differentiate between AD and FTD and FTD is not in the 
differential diagnoses in this case, the request would not meet criteria for coverage. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan of the brain.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency care visit provided on 
February 14, 2022. 
 
You asked the Plan to waive the copayment for an emergency care 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 a $50 
copayment for Emergency care. 
 
You have been asked to pay a $50 copayment for an emergency care visit. This item/service falls within the 
Emergency care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency care 
visit provided on February 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the taxi transportation (A0100) provided on August 14, 2022. 
 
You asked the Plan to pay for the taxi transportation. You say that you consider this to be an emergency 
transportation because the pharmacy you were transported to was the closest one that would provide the 
required COVID-19 test. You also say that you had no choice but to take a taxi to the pharmacy, as it was the 
only form of transportation at the time. The Plan denied your request. The Plan says you do not have a 
supplemental benefit that covers non-emergent transportation by a vehicle that is not an ambulance. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of the taxi transportation have not been met. Therefore, we decided that 
the Plan does not have to pay for the taxi transportation (A0100) provided on August 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Medicare-covered surgery or other services 
provided at an outpatient hospital provided on January 18, 2022, to February 8, 2022. 
 
You asked the Plan to waive the copayment for Medicare-covered surgery or other services provided at an 
outpatient hospital. 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 $395 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 You have been asked to pay $395 copayment for each Medicare-covered surgery or other services provided at 
an outpatient hospital. This item/service falls within the Outpatient Surgery and Other Medical Services 
Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 Medicare-covered surgery or other services provided at an outpatient 
hospital provided on January 18, 2022, to February 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for colonoscopy provided on September 1, 
2022. 
 
You asked the Plan to waive the deductible for colonoscopy. 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 $818.11 
deductible for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
The record shows you are responsible for the amount applied to your deductible even though the procedure was 
unable to be completed. 
 
You have been asked to pay $818.11 deductible for colonoscopy. This item/service falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 deductible for colonoscopy provided on September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150) and panoramic radiographic image (D0330) provided on August 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that the billed services should be paid by your 
insurance because you have not had any x-rays in the last five years. 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. This benefit includes the 
requested comprehensive oral evaluation - new or established patient (D0150) but is limited to one procedure 
code every 3 calendar years and panoramic radiographic image (D0330) but is limited to one procedure code 
every 5 calendar years. 
 
  We looked at the file, the Plans rules, and Medicares rules. You previously received covered comprehensive 
oral evaluation on June 23, 2022, and received covered complete series x-ray on June 23, 2022. Although 
panoramic radiographic image and complete series x-ray are two different services, they fall within the same 
category in your Evidence of Coverage and are subject to the same frequency limitations.  Therefore, these 
benefits were exhausted on June 23, 2022. Therefore, we decided that the Plan does not have to pay for 
comprehensive oral evaluation - new or established patient (D0150) and panoramic radiographic image 
(D0330) provided on August 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 30, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable.  
 
 
 
 
  
 
Therefore, we decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) 
of service June 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on July 12, 2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that you are appealing the claim payment 
denial. 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 domiciliary or rest home 
visit provided on July 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628). 
 
You asked the Plan to pre-approve Intracept procedure. You say that the requested procedure is safe and 
effective for the enrollee. The Plan denied your request. The Plan says the requested procedure 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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary or reasonable at this time. The reviewer found 
there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the requested Intracept procedure is not medically reasonable or 
necessary in this case.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) (64628).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on May 28, 2022, to August 27, 
2022. 
 
You asked the Plan to pay for psychotherapy. You say that you are sure this was authorized. 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 psychotherapy provided 
on May 28, 2022, to August 27, 2022.