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

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit, a gonioscopy, and 
diagnostic x-ray of the eye provided on March 23, 2023. 
 
You asked the Plan to reduce the copayment for a specialist office visit, a gonioscopy, and diagnostic x-ray of 
the eye. You say that you were billed $35 by the doctor at the office, and then you received an extra bill for $9. 
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 $44 
copayment for all other physician services to diagnose and treat diseases and conditions of the eye.  
 
 You have been asked to pay a $44 copayment for a specialist office visit, a gonioscopy, and diagnostic x-ray of 
the eye. This item/service falls within the other physician services to diagnose and treat diseases and conditions 
of the eye 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 copayment for a specialist office visit, a 
gonioscopy, and diagnostic x-ray of the eye provided on March 23, 2023.  
 
Your complaint about the provider potentially overcharging you is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services provided on September 17, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Review of the file shows that the enrollee had two 
ambulance services on the same date of service. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have been met. Therefore, we decided that the Plan has to pay for the 
ambulance services provided on September 17, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that the medical records show medical necessity. The 
Plan denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown - porcelain/ceramic (D6740), and pontic - 
porcelain/ceramic (D6245) provided on February 1, 2023. 
 
You asked the Plan to pay for the retainer crown - porcelain/ceramic and pontic - porcelain/ceramic. The Plan 
denied your request. The Plan says dental codes D6245 and D6740 are not on the list of covered benefits under 
this 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 retainer crown - porcelain/ceramic 
and pontic - porcelain/ceramic are not among those covered under this benefit.  Therefore, we decided that the Plan does not have to pay for a retainer crown - porcelain/ceramic (D6740), and 
pontic - porcelain/ceramic (D6245) provided on February 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 23, 2022. 
 
You asked the Plan to pay for an office visit. You say that the provider is in-network with the Plan. 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 provided 
on August 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair repair services to be provided by an 
OON provider.  
 
You asked the Plan to pre-approve the wheelchair repair services. You say that you are the original providers of 
the wheelchair, and other providers were not able to provide this service. The Plan denied your request. The 
Plan says there are network providers who can provide this service. 
 
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 Plan says you are 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 wheelchair 
repair services to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hip surgery. 
 
You asked the Plan to pre-approve a hip surgery. You say that you need this surgery. The Plan denied your 
request. The Plan says this surgery is not medically indicated to be done on an urgent/emergent basis. 
 
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 a hip surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the surgery is not emergent in nature. The enrollee has multiple comorbids and smokes. It is 
reasonable for the enrollee to stop smoking prior to the surgery to reduce risk. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a hip surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a hip surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a podiatry office visit provided on January 23, 2023. 
 
You asked the Plan to pay for a podiatry office visit. 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 a podiatry office visit 
provided on January 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for elbow arthrocentesis provided on December 30, 2022. 
 
You asked the Plan to pay for elbow arthrocentesis. 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 elbow arthrocentesis 
provided on December 30, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on September 16, 2022. 
 
You asked the Plan to pay for physical therapy. You say that you are appealing with supporting medical 
records. The Plan denied your request. The Plan says the record only documents a diagnosis of TMJ which is 
insufficient for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a diagnosis of TMJ on a claim is insufficient and 
the actual condition or symptom must be determined.  
 
We looked at the file and Medicare rules. The sole diagnosis of TMJ is insufficient. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that 
the Plan does not have to pay for physical therapy provided on September 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic injections provided on February 16, 2023. 
 
You asked the Plan to pay for therapeutic injections. You say that the service was 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 therapeutic injections 
provided on February 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, open, sacroiliac (SI) joint (27280). 
 
You asked the Plan to pre-approve arthrodesis, open, SI joint. You say that this is medically necessary. The 
Plan denied your request. The Plan says the requested service is considered experimental or investigational 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve arthrodesis, open, SI joint. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation is not evident regarding imaging or radiographic 
evidence supporting a sacroiliitis pathology. Multiple other plausible pain generators including at the 
lumbosacral spine are evident. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis, open, SI joint have not been met. Therefore, we decided that the 
Plan does not have to pre-approve arthrodesis, open, sacroiliac (SI) joint (27280).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99205), a panoramic x-ray of the jaw 
(70355), an unlisted dental surgery procedure (41899) and a consultation with a medical health care 
professional (D9311). 
 
You asked the Plan to pre-approve dental services. You say that two different oral surgeons have declined to 
provide the services in a dental office. They have referred the enrollee to a facility that is more capable of 
handling medical emergencies. The Plan denied your request. The Plan says the requested services are not a 
covered benefit with the enrollee's 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 an 
office visit (99205), a panoramic x-ray of the jaw (70355), an unlisted dental surgery procedure (41899) and a 
consultation with a medical health care professional (D9311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on December 4, 2022. 
 
You asked the Plan to pay for initial hospital care. 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 for enrollees who are registered hospital 
inpatients or outpatients, the inpatient or outpatient hospital POS code would be reported regardless of where 
the face-to-face service takes place. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of initial hospital care have not been met. Specifically, the case record documents that the enrollee 
was in outpatient observation status on the date of service at issue. The claim at issue has been incorrectly billed with an inpatient POS code. Therefore, we decided that the Plan does not have to pay for initial hospital 
care (99223) provided on December 4, 2022.
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 the enrollee would not make necessary progress at a 
lower level of care. The Plan denied your request. The Plan says the IRF services you are requesting do not 
meet the requirements for approval. 
 
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 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 2, 2022, to May 
31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that a system issue with your 
electronic claim vendor caused the date of admission to be incorrect on the claim. The Plan denied your 
request. The Plan says the claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 2, 2022, to May 31, 
2022.  
 
Please note that you indicated in additional information you submitted to us that you have discovered the 
billing issue with the admission date on the claim and have submitted a corrected claim.  This corrected claim 
has not, to our knowledge, been received or adjudicated by the Plan.  Please contact the Plan directly regarding 
the submission of your corrected claim.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the inpatient hospital stay provided by an 
in-network provider from January 20, 2022, to January 21, 2022. 
 
You asked the Plan to waive the coinsurance for the inpatient hospital stay. You say that you already met your 
out-of-pocket maximum. 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 15% 
coinsurance each time you are admitted for an in-network Medicare-covered hospital stay. 
 
 You have been asked to pay a $856.33 coinsurance for the inpatient hospital stay because your out-of-pocket 
maximum was met partway through the 15% coinsurance. 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 coinsurance for the inpatient hospital stay 
provided by an in-network provider from January 20, 2022, to January 21, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 90471 and 90715 for date of service 
February 19, 2023. 
 
You asked the Plan to pay for procedure codes 90471 and 90715. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be billed correctly. 
 
We looked at the file and Medicare rules. Review of the file shows that code 90471 has a status indicator of 
Q1. Code 99283 was billed on the same date of service with revenue code 450 which has a status indicator of 
"V". This code is not payable as billed. Code 90715 has a status indicator of "N".  This means this code is 
never separately payable. Based on this information, we decided that Medicare rules for coverage of procedure codes 90471 and 90715 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 90471 and 
90715 for date of service February 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88305 billed for date of service January 23, 
2023. 
 
You asked the Plan to pay for procedure codes 88305. You say that the pathology report supports the services 
billed. The Plan denied your request. The Plan says this code is included in the facility payment and is not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT code 88305. This means there is both a 
professional and technical component for the CPT code. In this case, an appropriate modifier to indicate the 
professional component has not been billed. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
88305 billed for date of service January 23, 2023.