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

 
We decided that the Plan does not have to pay for psychotherapy provided on May 4, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the provider is not eligible to bill Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that certain individuals and entities frequently 
attempt to enroll in Medicare but are not eligible to do so. If the Medicare contractor receives an enrollment 
application from the individual or entity, the contractor shall deny the application. Licensed Professional 
Counselor (LPC) is among the provider types that are not eligible to enroll in Medicare.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Therefore, we decided that the Plan does not have to pay for 
psychotherapy provided on May 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for follow-up nursing facility visits provided on January 23, 
2023, to March 20, 2023. 
 
You asked the Plan to pay for follow-up nursing facility visits. You say that you are requesting reconsideration 
for 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 follow-up nursing 
facility visits provided on January 23, 2023, to March 20, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospice services provided from April 4, 2023, to April 30, 
2023. 
 
You asked the Plan to pay for hospice services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospice services provided from April 4, 2023, to April 30, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable chest and hip x-rays provided on June 06, 2023. 
 
You asked the Plan to pay for portable chest and hip x-rays. You say that there was no time to obtain 
authorization. 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 portable chest and hip x-
rays provided on June 06, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11750 provided on March 25, 2023. 
 
You asked the Plan to pay for procedure code 11750. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim was not billed with a valid diagnosis code. 
 
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 11750 is Excision of nail and nail matrix, partial or 
complete. 
 
We find that CPT code 11750 is not supported in the medical record. Specifically, the claim was not billed with 
a covered diagnosis code per Local Coverage Determination Reference Article: Billing and Coding Article: 
Surgical Treatment of Nails (A52998). Based on this information, we decided that Medicare rules for coverage of procedure code 11750 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 11750 provided on March 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device.  
 
You asked the Plan to pre-approve the Vertiflex Superion Interspinous device. You say that this is a Medicare 
covered benefit and ample proof has been provided that the procedure is warranted. You say that there is no 
evidence that the Plans determination involved review by a peer equivalent physician. The Plan denied your 
request. The Plan says the Vertiflex Superion Interspinous device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex Superion Interspinous 
device. Our reviewer says that the Vertiflex Superion Interspinous device is not medically necessary. Our 
physician reviewer found that the Vertiflex Superion Interspinous device is considered experimental. 
 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 Vertiflex Superion Interspinous device. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic care provided on August 09, 2023. 
 
You asked the Plan to pay for the chiropractic care. You say that you would like to appeal your denial of 
service because you need a spinal manipulation done a few times a month an you cant use medication. 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 chiropractic care 
provided on August 09, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services provided on March 08, 2023, to March 19, 
2023. 
 
You asked the Plan to pay for x-ray services. You say that there was no time to obtain authorization. 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 x-ray services provided 
on March 08, 2023, to March 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from this care. 
The Plan denied your request. The Plan says the enrollee's needs can be safely managed at the current facility 
until they are more stable for transfer to another level of care.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee's care can be safely provided at the current facility until they are more 
stable and appropriate for transfer to another level of care. Completion of treatment at the current facility is 
recommended.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a DEXA bone scan provided on September 21, 2023. 
 
You asked the Plan to pay for a DEXA bone scan. The Plan denied your request. The Plan says according to 
our records, your last bone density measurement test was done on November 4, 2022. There was no request for 
additional bone density measurement. This is in excess of the allowed benefit, and not covered. 
 
The Plan contract says or qualified individuals (generally, this means people at risk of losing bone mass or at 
risk of osteoporosis), the following services are covered every 24 months or more frequently if medically 
necessary: procedures to identify bone mass, detect bone loss, or determine bone quality, including a 
physicians interpretation of the results. 
 
We looked at the file and the Plans rules. Based on this information, we decided that Medicare rules for 
coverage of a DEXA bone scan have not been met. Therefore, we decided that the Plan does not have to pay 
for a DEXA bone scan provided on September 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
from July 27, 2023, to August 1, 2023. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you have so many bills from this 
year that you are trying to sort out. You must have hit your maximum-out-of-pocket (MOOP) amount by this 
time. 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 $295 
copayment per day, for days one to six for inpatient care.  
 
You have been asked to pay $689 towards that MOOP amount listed in your 2023 Evidence of Coverage.  
 You have been asked to pay a $689 copayment for an inpatient stay. This item/service falls within the inpatient 
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 in-network acute inpatient 
stay provided from July 27, 2023, to August 1, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection provided on June 28, 2023. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you cannot afford to pay this much 
and you have never paid this amount. 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 prescription drugs. 
 
You have been asked to pay 20% coinsurance for the injection. This item/service falls 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. The total you owe is $678.42 ($3,392.10 allowed amount x 20% = $678.42). Therefore, we decided 
that the Plan does not have to waive the coinsurance for the injection provided on June 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided by an 
in-network provider from April 5, 2023, to April 17, 2023, and May 21, 2023, to May 28, 2023. 
 
You asked the Plan to reduce the copayment for the inpatient hospital stays. You say that the enrollee is being 
billed for the private room rate. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $160 copayment per day, days 1-10, for in-network inpatient hospital care. 
 
 The enrollee has been asked to pay a $1,600 copayment for the inpatient stay provided from April 5, 2023, to 
April 17, 2023 ($160 copayment x 10 days = $1,600). The enrollee has also been asked to pay a $1,120 
copayment for the inpatient stay provided from May 21, 2023, to May 28, 2023 ($160 copayment x 7 days = 
$1,120). These items/services fall within the inpatient hospital care benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to reduce the copayment for the inpatient hospital stay provided by an in-network provider from 
April 5, 2023, to April 17, 2023, and May 21, 2023, to May 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit, and home health services provided 
on June 27, 2023, to July 26, 2023. 
 
You asked the Plan to pay for a new patient office visit, and home health services. You say that you were not 
notified that the provider was out-of-network. 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, and home health services provided on June 27, 2023, to July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 28, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for 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 an office visit provided 
on June 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (ECG), and x-ray services provided on 
April 22, 2023, to June 07, 2023. 
 
You asked the Plan to pay for an electrocardiogram (ECG), and x-ray services. You say that there was no time 
to obtain authorization. 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 electrocardiogram 
(ECG), and x-ray services provided on April 22, 2023, to June 07, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vestibuloplasty (D7350). 
 
You asked the Plan to pre-approve D7350. You say that you would like the Plan to pre-approve this dental 
work. The Plan denied your request. The Plan says the requested dental service is not a covered benefit. 
 
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 
vestibuloplasty (D7350).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on May 30, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. 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 genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided on 
May 30, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable chest x-ray provided on July 26, 2023. 
 
You asked the Plan to pay for a portable chest x-ray. You say that there was no time to obtain authorization. 
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 portable chest x-ray 
provided on July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mechanical traction therapy provided by a chiropractic on 
July 10, 2023, to, July 20, 2023. 
 
You asked the Plan to pay for the mechanical traction therapy. You say that you have a bulging disc, and it 
cant be fixed by a physical therapist. The Plan denied your request. The Plan says that the only covered 
chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the mechanical traction therapy provided by a chiropractic on July 10, 2023, 
to, July 20, 2023.