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

 
We decided that the Plan does not have to pay for the Tdap vaccination and its administration. 
 
You asked the Plan to pay for the Tdap vaccination and administration. You say that your doctor and you 
agreed it would be beneficial to get this vaccination. The Plan denied your request. The Plan says that their first 
decision to deny payment was correct. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap 
vaccination and administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Tdap 
vaccination and administration. Therefore, we decided that the Plan does not have to pay for the Tdap 
vaccination and its administration.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the laboratory services to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the laboratory services. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says this service is available with in-network 
providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the laboratory services to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 28, 2023. 
 
You asked the Plan to pay for the office visit. You say that you have an authorization for these services. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on April 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the required services can be provided in an alternate 
setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. The enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incomplete endodontic therapy (D3332) provided on April 
25, 2023. 
 
You asked the Plan to pay for the dental service. You say that you had an appointment for a covered procedure. 
You say it is not your fault that the procedure was not completed and feel you should be reimbursed. The Plan 
denied your request. The Plan says this service is not a covered expense under your dental 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
incomplete endodontic therapy (D3332) provided on April 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 7, 2023, 
through April 8, 2023. 
 
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 acute inpatient hospital care provided was 
not medically necessary.   
 
 
 
 
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) with report of a possible 
pseudoaneurysm of the left common femoral artery. He reported no complaints or symptoms. Imaging was 
performed showing no evidence of a pseudoaneurysm or other abnormal findings warranting inpatient services. 
The enrollee's vital signs were stable. It was not expected that this enrollee would have required hospital 
services that would have likely crossed two 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from April 7, 2023, through April 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crowns (D6740 x3) and a pontic (D6245) provided 
on April 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that the pontic and crown should be covered as it is 
an integral part of the crown and holds position of the adjoining teeth. The Plan denied your request. The Plan 
says dental codes D6245 and D6740 are not covered benefits under the dental 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 pay for retainer 
crowns (D6740 x3) and a pontic (D6245) provided on April 17, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code S9485 billed on an outpatient hospital claim for date of 
service April 6, 2023. 
 
You asked the Plan to pay for the outpatient hospital services. You say that the coding on this claim is correct. 
The Plan denied your request. The Plan says billed code S9485 is not valid for Medicare purposes, so this claim 
cannot be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that codes with a status indicator of E1 are not 
covered or recognized by Medicare.  In this case, code S9485 has a status indicator of E1.  As a result, this 
claim cannot be processed.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient hospital services have not been met. Therefore, we decided that the Plan does not 
have to pay for code S9485 billed on an outpatient hospital claim for date of service April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on April 4, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the home health services. You say that you are requesting reconsideration for the 
denied claim. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 home health services provided on April 4, 
2023, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy and biopsy provided on May 23, 2023. 
 
You asked the Plan to pay for the colonoscopy and biopsy. You say that you were not made aware 
authorization was required. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the colonoscopy and 
biopsy provided on May 23, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction study provided on March 29, 2023. 
 
You asked the Plan to pay for the nerve conduction study. You say that you are requesting 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 the nerve conduction 
study provided on March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on July 18, 
2023. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you disagree with 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 $45 
copayment for urgently needed services. 
 
You have been asked to pay a $45 copayment for an urgent care visit. This item/service falls within the 
urgently needed 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 an urgent 
care visit provided on July 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hip arthroplasty to be provided by an OON provider.  
 
You asked the Plan to pre-approve the hip arthroplasty. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says this service is available with in-network 
providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The record shows you are not contracted with the Plan. The Plan has network providers available who can 
provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the hip 
arthroplasty to be provided by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each cardiac rehabilitation service provided 
on May 03, 2023, to May 31, 2023. 
 
You asked the Plan to waive the copayment for each cardiac rehabilitation service. You say that you were not 
informed in advance that you would have a 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 $20 
copayment for cardiac rehabilitation services.  
You have been asked to pay a $20 copayment for each cardiac rehabilitation service. This item/service falls 
within the cardiac rehabilitation 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. The total amount you owe is $220 ($20 copayment x 11 visits = $220). 
Therefore, we decided that the Plan does not have to waive the copayment for each cardiac rehabilitation 
service provided on May 03, 2023, to May 31, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99310 provided on March 30, 2023. 
 
You asked the Plan to pay for procedure code 99310. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the claim is a duplicate of a claim that was 
already paid for. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan did not provide enough evidence to support the denial of 
payment for the second claim for procedure code 99310 based on Medicare criteria. The Plan should have 
provided the first claim for procedure code 99310 showing that it had already paid. The Plan did not provide 
the first claim for verification. Therefore, we decided that the Plan has to pay for procedure code 99310 
provided on March 30, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services and a hospital outpatient clinic visit for 
assessment and management provided on May 18, 2023. 
 
You asked the Plan to pay for laboratory services and a hospital outpatient clinic visit for assessment and 
management. You say that this service 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 laboratory services and a 
hospital outpatient clinic visit for assessment and management provided on May 18, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve the medication. You say that records have been provided to show medical 
necessity. The Plan denied your request. The Plan says the enrollee has not tried and failed preferred 
medications. 
 
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 the medication. Our reviewer says that 
the requested medication does not meet the requirements for step therapy guidelines. Our physician reviewer 
found the Plan requires a trial of Infed and Venofer before they will approve the requested drug. The records do 
not show that the enrollee has tried and failed the required drugs. The records also do not show that the Plans 
required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Feraheme.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99222) and laparoscopic 
cholecystectomy (47562) provided from May 16, 2023, to May 17, 2023. 
 
You asked the Plan to pay for the outpatient services. You say that the enrollee does not have other insurance. 
You say that the services were medically necessary. You also say that the claim should be reprocessed and 
paid. The Plan denied your request. The Plan says the evidence of benefits (EOB) has not been received from 
the primary insurer. 
 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 directed the 
provider to submit the claim to the enrollee's primary insurer. As the secondary insurer, the Plan cannot be held 
responsible for the outpatient services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for the initial hospital care (99222) and laparoscopic 
cholecystectomy (47562) provided from May 16, 2023, to May 17, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service June 22, 
2023. 
 
You asked the Plan to pay for procedure code 99232. You say that you have billed the services at issue 
correctly. 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 providers must report services correctly. 
 
We find that CPT code 99232 is not supported. Specifically, code 99232 has been billed with modifier "HE," 
which designates a non-covered service. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99232 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99232 billed for date of service June 22, 2023.