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

 
We decided that the Plan does not have to pay for the physician visit, laboratory and urinalysis services 
provided on August 28, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician visit, laboratory and urinalysis services. You say that the services 
were medically necessary and did not require a referral. The Plan denied your request. The Plan says the 
services do not meet the criteria for coverage. 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 had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 physician visit, laboratory and urinalysis services provided on August 28, 2023, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
October 2, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the nursing facility care. You say that you are requesting for review of the 
documents and to grant the appeal for payment. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 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 had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 subsequent nursing facility care (99309) provided on October 2, 2023, by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on September 
27, 2023. 
 
You asked the Plan to pay for the dental service. You say that this should be covered by your plan. The Plan 
denied your request. The Plan says your benefit for this 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 this service was exhausted on the date of service in this case. Therefore, we decided that 
the Plan does not have to pay for the complete series x-ray (D0210) provided on September 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on July 31, 2023. 
 
You asked the Plan to pay for the podiatry services. You say that these 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 podiatry services provided on July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasonic guidance for placement of radiation therapy fields 
(G6001) provided from May 2, 2023, to June 12, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says daily imaging is neither necessary nor useful when treating with electron beam, 
superficial radiotherapy, or skin surface brachytherapy. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the treatment itself is not disputed in this case but rather the need for image guidance. Usually 
image-guided radiation therapy (IGRT) is used when critical structures are abutting or in close proximity to the 
target that is being treated to high doses. This situation does not apply to this patient for which the target lesion 
can be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for 
IGRT unless deep structures are being treated. Certainly, using ultrasound on a daily basis is not unreasonable 
to offer but not necessary. The device itself is Food and Drug Administration (FDA) approved for use with 
ultrasound though that in and of itself does not mean that daily imaging is necessary but simply that the device 
was designed to incorporate this functionality. Therefore, to bill for daily simple simulations (77280) and/or 
IGRT for a technology for which need has not been established by published data or supported by consensus 
guidelines (many of which recommend against treatment with these devices in general- citations below) is not 
necessary. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for ultrasonic guidance for placement of radiation therapy fields (G6001) provided from May 2, 
2023, to June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99457 and 99458 rendered on September 
30, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the billed services are not supported. 
 
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 the denied codes is: 
 
CPT 99457: 
 
Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver 
during the month; first 20 minutes 
 
CPT 99458: 
 
Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health 
care professional time in a calendar month requiring interactive communication with the patient/caregiver 
during the month; each additional 20 minutes (List separately in addition to code for primary procedure) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that at issue is the appropriateness of 
CPT codes 99457 and 99458 on September 30, 2023. There is no documentation to support that this work was 
performed on that date. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99457 and 99458 rendered on September 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on October 2, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the home visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services rendered are not a covered benefit. 
 
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 had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 visit provided on October 2, 2023, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided on August 16, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the mental health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not covered when rendered by an OON 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 mental health services provided on August 16, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiographic recording provided 
on October 4, 2023. 
 
You asked the Plan to waive the copayment for an electrocardiographic recording. You say that you had met 
your MOOP amount prior to this service. 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 $75 
copayment for each Medicarecovered diagnostic procedure and test.  You have been asked to pay a $75 copayment for an electrocardiographic recording. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. The record shows 
you had not met your MOOP amount prior to this service. 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 electrocardiographic recording provided on October 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two-dimensional (2D) oral/facial photographic image 
(D0350) provided on September 5, 2023. 
 
You asked the Plan to pay for 2D oral/facial photographic image. You say that you did not request these x-rays 
nor were you given the chance to decline. The Plan denied your request. The Plan says this 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 pay for two-
dimensional (2D) oral/facial photographic image (D0350) provided on September 5, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept service (A0432) provided on July 27, 
2023. 
 
  You asked the Plan to pay for the paramedic intercept service. You say that you had a medical emergency, 
were treated by emergency medical technicians (EMTs) on site, then transported by ambulance, with the same 
EMTs in attendance, to the hospital. You also say that this should be covered by your plan. The Plan denied 
your request. The Plan says no payment can be made for the advanced life support (ALS) paramedic intercept 
service. 
 
The rules say that Medicare pays for ALS, in accordance with state and local laws by an emergency medical 
technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS 
paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted 
that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept service (A0432) provided on July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic consultation (D9310) provided on July 27, 2023. 
 
You asked the Plan to pay for a diagnostic consultation. You say that the panoramic x-ray from July 27, 2023, 
should have been at no cost to you because you are allowed one. You also say you had to pay $124. You also 
say you are requesting the $124 to be reimbursed to you for a service you were supposed to get at no charge. 
The Plan denied your request. The Plan says there is no coverage for this service. 
 
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. The record shows that the denied service was the consultation 
(D9310). Therefore, we decided that the Plan does not have to pay for a diagnostic consultation (D9310) 
provided on July 27, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Fulphila. 
 
You asked the Plan to pre-approve Fulphila. You say that the medication i medically necessary. The Plan 
denied your request. The Plan says that the medication is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Fulphila. Our reviewer says that the 
medication is medically necessary. Our physician reviewer found the PEACE-1 Trial showed that Combining 
androgen deprivation therapy, docetaxel, and abiraterone in de novo metastatic castration-sensitive prostate 
cancer improved overall survival. Therefore, the systemic therapy using Docetaxel in addition to 
leuprolide/abiraterone/prednisone should be approved. Further, Docetaxel carries a high risk of febrile 
neutropenia and prophylaxis is recommended. Therefore, Fulphila is also medically reasonable and necessary. 
Fulphila has been used commonly for enrollees with a high risk of febrile neutropenia and is shown to be safe 
and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fulphila have been met. Therefore, we decided that the Plan has to pre-approve 
Fulphila.  
 
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 waive the copayment for the dermatology office visits provided on 
May 19, 2023, and June 30, 2023. 
 
You asked the Plan to waive the copayment for the office visits. You say that you should not 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 $35 
copayment for an in-network specialist office visit.  
 You have been asked to pay a $35 copayment for each office visit. These services fall within the 
physician/practitioner 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 
the dermatology office visits provided on May 19, 2023, and June 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on July 24, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you disagree with the denial of payment and 
have submitted all the relevant documents for review. You also request that the claim is reprocessed and paid. 
The Plan denied your request. The Plan says you are not enrolled in Medicare as a durable medical equipment 
supplier. Therefore, the claim will remain denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided on July 
24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the gastric emptying imaging study 
provided on August 31, 2023. 
 
You asked the Plan to reduce the copayment for the gastric emptying imaging study. You say that you were 
told that you would only have a $15 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 $150 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $150 copayment for the gastric emptying imaging study. This item/service falls within the in-network outpatient diagnostic tests and therapeutic services and supplies 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 the gastric emptying imaging study provided on August 31, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service July 31, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the documentation justifies the services 
performed. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
 The urinary tract infection panel testing was billed using codes 87481, 87460, 87653, 87798, 87150, and 
87641. We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic 
acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits 
were used in this case. As such, a single code with one unit of service should be used. Based on this 
information, we decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the panel testing billed for date of service July 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on September 
30, 2022. 
 
You asked the Plan to pay for the periodontal maintenance (D4910). You say that you are required to receive 
this treatment because of your preexisting condition. The Plan denied your request. The Plan says the 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 periodontal maintenance (D4910) 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910) provided on September 30, 2022.