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

 
We decided that the Plan does not have to pay for the medical eye exam provided on June 24, 2022, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the medical eye exam. You say that the services were provided at the enrollee's 
residence and the enrollee did not have the option to choose the provider. The Plan denied your request. The 
Plan says the provider was out-of-network. 
 
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 
medical eye exam. We found no exception that would require the Plan to pay for the medical eye exam. 
Therefore, we decided that the Plan does not have to pay for the medical eye exam provided on June 24, 2022, 
by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on 
October 13, 2021. 
 
You asked the Plan to pay for the emergency department visit. You say that the filing limit has not expired. The 
Plan denied your request. The Plan says the claim was untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department visit was not filed until March 2, 2023. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on 
October 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulmonary rehabilitation via telemedicine. 
 
You asked the Plan to pre-approve telehealth pulmonary rehab. You say that the pulmonary rehabilitation 
facility is far away from your home. The Plan denied your request. The Plan says pulmonary rehabilitation is 
not covered by telemedicine after the end of the COVID-19 public health emergency (PHE). 
 
The Plan must follow Medicare rules. Medicare rules say that pulmonary rehabilitation services via telehealth 
were only covered during the COVID-19 Public Health Emergency (PHE).  
 
We looked at the file and Medicare rules. As the COVID-19 PHE has formally ended, pulmonary rehabilitation 
services are no longer covered via telehealth. These services must be performed in a physicians office or 
outpatient hospital facility. Based on this information, we decided that Medicare rules for coverage of 
telehealth pulmonary rehab have not been met. Therefore, we decided that the Plan does not have to pre-
approve pulmonary rehabilitation via telemedicine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a visual field assessment (0379T) provided on December 19, 
2022. 
 
You asked the Plan to pay for a visual field assessment (0379T). You say that the physician determined the test 
was medically necessary in determining the best course of treatment. 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 visual field assessment 
(0379T) provided on December 19, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014) and an 
eye refraction (92015) provided on February 17, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination (92014) and an eye refraction 
(92015). You say that you are concerned with being charged a copyament for the date of service at issue. 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 $35 
copayment for Medicare-covered vision examination. 
 
You have been asked to pay a $35 copayment for a medical eye examination (92014) and an eye refraction 
(92015). This item/service falls within the Medicare-covered vision examination 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 medical eye examination (92014) and an eye refraction (92015) 
provided on February 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 10, 2021, to 
August 18, 2021, at the Diagnosis Related Group (DRG) originally billed.  
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the DRG billed is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with T81.11XA, defined as postprocedural cardiogenic 
shock, initial encounter. 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that the documentation does not support the 
DRG billed. Our physician reviewer found the enrollee presented to the facility for elective redo mitral valve 
replacement. The past medical history was significant for osteoarthritis, paroxysmal atrial fibrillation, and 
severe symptomatic mitral regurgitation status post replacement in 2017. The enrollee underwent full 
sternotomy with replacement of mitral valve. Surgery was uneventful, and the enrollee was discharged for 
follow-up with Cardiology. there was no clinical or laboratory evidence of Postprocedural cardiogenic shock. 
The patient was weaned from vasopressor support within 24 hours postoperatively. In addition, there was no 
indication that the minimal vasopressor support required was an unexpected complication. Therefore, the DRG 
billed is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 10, 2021, to August 18, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on April 18, 2023. 
 
You asked the Plan to pay for an outpatient mental health visit. You say that the records attached support the 
services provided. 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 outpatient mental 
health visit provided on April 18, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on 
January 25, 2023. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you had a total 
knee replacement on January 23, 2023 and you fell on January 25, 2023 and could not get up and called the 
ambulance to help as your wife was not able to lift you off of the floor. You say that the fall did not cause any 
injury so you refused transport to the hospital. The Plan denied your request. The Plan says Per Medicare, an 
ambulance service provided without transport is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 25, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
provided on January 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an IRF stay provided from March 5, 2023, 
to March 23, 2023. 
 
You asked the Plan to waive the copayment for an IRF stay. You say that you should not have to pay the 
copayment for the rehabilitation stay when your secondary insurance would have covered 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 $225 
copayment per day for days 1 to 6 and $0 copayment for additional days for inpatient hospital care.  
 
 You have been asked to pay a $1,350 copayment for an IRF stay ($225 per day x 6 days = $1,350). 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 an IRF stay provided from March 5, 2023, to March 23, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on January 17, 2023. 
 
You asked the Plan to pay for nursing facility care. 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 nursing facility care 
provided on January 17, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on November 14, 2022. 
 
You asked the Plan to pay for wound care. 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 wound care provided on 
November 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 15, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says you received the 
services from a provider who chose not to receive Medicare funds. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit provided on September 15, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on December 02, 2022, to 
December 30, 2022. 
 
You asked the Plan to pay for physical therapy. 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 physical therapy 
provided on December 02, 2022, to December 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient office visit provided on January 04, 2023, to 
March 23, 2023. 
 
You asked the Plan to pay for outpatient office visit. You say that you would like to be reimbursed for the 
billed charges. 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 outpatient office visit 
provided on January 04, 2023, to March 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the dentures. 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 complete denture - maxillary and complete denture - mandibular was exhausted on 
date of service October 20 2022. Therefore, we decided that the Plan does not have to pre-approve a complete 
denture - maxillary (D5110), and complete denture - mandibular (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an abutment 
support to crown (D6058) for tooth #21. 
 
You asked the Plan to pre-approve the dental services. You say that the provider only placed 1 implant because 
the other implant was lost. The Plan denied your request. The Plan says your benefit for the requested items or 
services 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 the Plan approved the surgical placement of implant body (D6010), and the surgical access to an implant 
body (D6011) for tooth #5 and #12, and the custom fabricated abutment (D6057) and abutment support to 
crown (D6058) for tooth #8 and #20 on March 20, 2023. Furthermore, the record show the Plan paid for the 
surgical placement of implant body (D6010) and surgical access to an implant body (D6011) for tooth #5 and 
#12 on April 26, 2023; therefore, your benefit for the requested items or services was exhausted on the date of 
service of April 26, 2023. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated 
abutment (D6057) and an abutment support to crown (D6058) for tooth #21.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 87636 for date of service 
January 4, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 
87636 for date of service January 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that you would like a CGM. The Plan denied your request. 
The Plan says the medical criteria for CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose 
monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removable prosthodontic procedure (D5899), an 
abutment supported removable denture (D6111), a semi-precision abutment (D6191), and a semi-precision 
attachment (D6192) for tooth #3, #6, #8, #11, #19, #22, #24, #25, #27, and #30. 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are necessary. 
The Plan denied your request. The Plan says the denial of authorization for these services is correct, because 
the removable prosthodontic procedure, an abutment supported removable denture, a semi-precision abutment, 
and a semi-precision attachment are not covered by the Plan. 
 
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 pre-approve a 
removable prosthodontic procedure (D5899), an abutment supported removable denture (D6111), a semi-
precision abutment (D6191), and a semi-precision attachment (D6192) for tooth #3, #6, #8, #11, #19, #22, #24, 
#25, #27, and #30.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of heart with 
evaluation of blood vessel calcium. 
 
You asked the Plan to pre-approve the CT scan of the heart. You say that the services are medically necessary.  
The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan of the heart. Our reviewer 
says that the CT scan is not medically necessary. Our physician reviewer found that CT imaging of the heart 
without contrast material with quantitative evaluation of coronary calcium is considered experimental and 
investigational for the evaluation and management of this enrollee's medical condition. 
 
 
 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 CT scan of the heart have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of heart with evaluation of blood vessel 
calcium.