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

 
We decided that the Plan does not have to pay for chiropractic services and radiologic examination provided on 
February 06, 2023, to February 24, 2023. 
 
You asked the Plan to pay for chiropractic services and radiologic examination. You say that the services 
should be covered. 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 chiropractic services and 
radiologic examination provided on February 06, 2023, to February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 14, 2023 by an out-of-
network provider. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. 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. This provider is not a network provider with the Plan and based on the documentation 
submitted, we have determined that the services rendered to the member are not urgent or emergent, nor were 
they approved in advance by a 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 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 an office visit provided on March 14, 2023 by an out-of-network 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for omentectomy, epiploectomy, resection of omentum (separate 
procedure) rendered on January 6, 2023. 
 
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 documents received do not support that CPT 49255 is separate and distinct from CPT 47562. 
 
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 49255 is "Omentectomy, epiploectomy, resection of 
omentum (separate procedure)." 
 
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 that the although the procedure was 
reported with modifier -59 (distinct procedural service), the operative report does not include documentation to 
support modifier billed. The operative report describes omental adhesions were removed through the same 
incision as the gallbladder removal. In this case, the claim denied correctly as modifier -59 is not 
supported. This procedure would be inclusive to the more comprehensive procedure which in this case is 
cholecystectomy. 
 
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 omentectomy, epiploectomy, resection of omentum (separate procedure) rendered on January 6, 
2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on December 13, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider must attempt to consult the attending or primary care physician 
about the services furnished and document the consent or declination date to consultations and the date of 
consultations in the patients medical record. If consultation with the attending or primary care physician is unsuccessful, document the patients medical chart with the date and manner of notification to the physician. 
There was no documented contact with the attending/primary care physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 1, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the member 
has no out-of-network benefits. No medical necessity for an out-of-network provider, such as an urgent or 
emergency situation, has been documented. There is no network deficiency for these services and alternate 
network providers were found. 
 
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 
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 physician's services provided on September 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for  in-network radiation therapy treatments 
provided from March 1, 2023, to March 21, 2023. 
 
You asked the Plan to waive the copayment for  in-network radiation therapy treatments. You say that this is a 
large copayment that you will have difficulty paying. 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 $65 
copayment for therapeutic radiology services (radiation). You had 15 visits, resulting in a total copayment of 
$975 ($65 x 15 visits = $975).  
 You have been asked to pay a $975 copayment for in-network radiation therapy treatments. This item/service 
falls within the therapeutic radiology services (radiation) 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  in-network radiation therapy treatments provided from March 1, 2023, to March 
21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service January 25, 
2023.  
 
You asked the Plan to pay for procedure code 99285. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99285 is bundled into payment for code 99223. 
 
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, we have confirmed that code 99285 
is a column II code to column I code 99223 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99285 billed for date of service January 25, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on March 28, 2023. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you say that if you receive a bill for 
this you will not pay it. 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 $30 
copayment for outpatient hospital services. 
 
You have been asked to pay a $30 copayment for ultrasound. This item/service falls within the outpatient 
hospital services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ultrasound provided 
on March 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 72050, 72110, 73521, & 73564 provided on 
January 26, 2023. 
 
You asked the Plan to pay for procedure codes 72050, 72110, 73521, & 73564. You say that this service was 
medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 72050, 72110, 73521, & 73564 are not supported in the medical record. Specifically, 
the fourth digit of the Type of Bill billed was zero, indicating a non-payment claim. Based on this information, 
we decided that Medicare rules for coverage of procedure codes 72050, 72110, 73521, & 73564 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 72050, 72110, 73521, & 
73564 provided on January 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 3, 2023, to January 6, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford the 
copayment. 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 $325 
copayment per day for days 1 through 6 per benefit period for inpatient hospital care. 
 
 
 You have been asked to pay a $975 copayment for the inpatient hospital stay ($325 x 3 days = $975). This 
item/service falls within the inpatient hospital 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 the inpatient hospital stay provided from January 3, 2023, to January 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), the bitewing x-
rays (D0272), and prophylaxis (D1110) provided on January 12, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting reconsideration of the 
processing of this claim. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
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 the Plan processed and approved payment on this claim. The record also shows you were 
reimbursed a total $69.70. You have been asked to pay the difference between the out-of-network providers 
charges and the Plans payment. 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 pay more for the periodic oral 
evaluation (D0120), the bitewing x-rays (D0272), and prophylaxis (D1110) provided on January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, and related services provided on January 02, 
2023. 
 
You asked the Plan to pay for an office visit, and related services. You say that this was the closest facility that 
would see you. 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 an office visit, and 
related services provided on January 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the infliximab injections and the saline 
solution infusion provided on March 7, 2023. 
 
You asked the Plan to reduce the coinsurance for the injections and the infusion. You say that you were 
charged incorrectly. 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 20% 
coinsurance for Medicare Part B non-chemotherapy prescription drugs. 
 
 
 
 You have been asked to pay $746, which is 20% coinsurance of the allowed amount for one injection 
($3,730.02 allowed amount x 20% = $746). You have also been asked to pay $20.92, which is 20% 
coinsurance of the allowed amount for the second injection ($104.58 allowed amount x 20% = $20.92). You 
have also been asked to pay $0.13, which is 20% coinsurance of the allowed amount for the infusion ($0.66 
allowed amount x 20% = $0.13). You have been asked to pay a total of $767.05 ($746 coinsurance + $20.92 
coinsurance + $0.13 coinsurance = $767.05). These items/services fall within the Medicare Part B prescription 
drugs benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to reduce the coinsurance for the infliximab injections and 
the saline solution infusion provided on March 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical procedures on the nails provided on February 07, 
2023. 
 
You asked the Plan to pay for surgical procedures on the nails. You say that you would like a reconsideration 
of the denied claim. 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 surgical procedures on 
the nails provided on February 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit provided on October 20, 2022. 
 
You asked the Plan to pay for a new patient office visit. You say that this is supported in the records. 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 a new patient office visit 
provided on October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote monitoring of physiologic parameter provided on 
April 06, 2023. 
 
You asked the Plan to pay for remote monitoring of physiologic parameter. You say that the services were 
medically necessary. 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 remote monitoring of 
physiologic parameter provided on April 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on January 18, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that the services should be covered. 
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 an office visit and 
related services provided on January 18, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Xgeva (J0897). 
 You asked the Plan to pre-approve Xgeva. You say that Xgeva is a medical necessity for the enrollee. The Plan 
denied your request. The Plan says step-therapy rules for coverage of Xgeva have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Xgeva. Our reviewer says that Xgeva is 
not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial 
of drugs pamidronate or zoledronic acid before they will approve the requested drug. The case file does not 
contain documentation of trial and failure of pamidronate or zoledronic acid. The provided documentation does 
not support that pamidronate or zoledronic acid would likely be less effective and/or would likely have adverse 
effects for the enrollee 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 Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Xgeva (J0897).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology (colorectal) screening provided on December 12, 
2022. 
 
You asked the Plan to pay for oncology (colorectal) screening. You say that the services should be covered. 
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 oncology (colorectal) 
screening provided on December 12, 2022.