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

 
We decided that the Plan does not have to pay for the office visit and the eye exam provided on June 27, 2023. 
 
You asked the Plan to pay for the office visit and the eye exam. 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 office visit and the 
eye exam provided on June 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram provided on March 
27, 2023. 
 
You asked the Plan to waive the copayment for an electrocardiogram. You say that you should not have to pay 
for pretesting when you the surgery was not completed. 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 $40 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $40 copayment for an electrocardiogram. This item/service falls within the 
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 waive the copayment for an electrocardiogram provided on March 27, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0428JN) provided on May 13, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the records do not support the number of units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 2 units of CPT code A0428JN are not supported in the medical record. The medical record only 
supports 1 units of CPT code A0428JN. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance services (A0428JN) provided on May 13, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for group psychotherapy services (90853) provided on July 12, 
2023. 
 
You asked the Plan to pay for group psychotherapy services (90853). You say that the services at issue were a 
medical necessity for the enrollee. 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 group psychotherapy 
services (90853) provided on July 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on June 19, 2023. 
 
You asked the Plan to pay for a telehealth 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 telehealth visit 
provided on June 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on February 
16, 2023. 
 
You asked the Plan to waive the copayment for outpatient surgery. 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 $325 
copayment for outpatient surgery/outpatientsurgery in an outpatient hospitalfacility. 
 
You have been asked to pay a $325 copayment for outpatient surgery. This item/service falls within the 
outpatient surgery/outpatientsurgery in an outpatient hospitalfacility 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 outpatient surgery provided on February 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a direct reline complete mandibular denture (D5731) 
provided on July 25, 2023. 
 
You asked the Plan to pay for D5731. You say that you were unaware this was not covered. The Plan denied 
your request. The Plan says the denied 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 pay for a direct 
reline complete mandibular denture (D5731) provided on July 25, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a guided tissue regeneration, of natural teeth-resorbable barrier, 
per site for tooth number 18 (D4266). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says that the requested service is not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a guided 
tissue regeneration when medically necessary and reasonable. 
 
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 guided tissue regeneration. Our 
reviewer says that the requested service is medically necessary. Our physician reviewer found that based on 
terminology, the description for current procedural terminology (CPT) code D4266 is guided tissue 
regeneration-resorbable barrier per site and does not specifically state "per tooth." A resorbable barrier would 
help aid a bone graft. It is a common practice to use a resorbable membrane and bone replacement together in 
order to prevent horizontal and vertical resorption of an area where a tooth is extracted. The requested service 
is medically reasonable and necessary for a bone graft after the extraction of a tooth to decrease the amount of 
shrinkage in the bone. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of this service have been met. Therefore, we decided that the Plan has to pre-
approve a guided tissue regeneration, of natural teeth-resorbable barrier, per site for tooth number 18 (D4266).  
 
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 pre-approve home infusion supplies and administration.  
 
You asked the Plan to pre-approve home infusion supplies and administration. You say that the requested home 
infusion supplies and administration are medically necessary. The Plan denied your request. The Plan says  the 
requested medication is self-administered, does not require an external infusion pump and it does not take 15 
minutes or longer to administer.  
 
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 home infusion supplies and 
administration. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the medication does not require an infusion pump 
for administration. The infusion pump as requested is not medically 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 home infusion supplies and administration.  have not been met. Therefore, we 
decided that the Plan does not have to pre-approve home infusion supplies and administration.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hip arthroplasty. 
 
You asked the Plan to pre-approve a hip arthroplasty. You say that the enrollee would benefit from this 
arthroplasty. The Plan denied your request. The Plan says there is no proof of failed conservative treatment 
options. 
 
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 arthroplasty. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided diagnostic imaging studies did not clearly corroborate any severe 
osteoarthritis of the right hip and did corroborate other plausible causes of the right hip pain. 
 
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 arthroplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a hip arthroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated wheelchair back cushion (E2617), 
replacement arm pads (K0019), back frame (K0108), back post (K0108), and back upholstery (K0108). 
 
You asked the Plan to pre-approve a custom fabricated wheelchair back cushion, replacement arm pads, back frame, back post, and back upholstery. The Plan denied your request. The Plan says a custom back cushion is not medically necessary and cannot be covered. Replacement arm pads are already included with the requested wheelchair and cannot be requested separately. The Plan also says the requested back frame, back post, and back upholstery are included with the requested custom back cushion (E2617) and cannot be requested separately. The Plan also says the notes do not clearly explain why a skin protection or positioning cushion are not sufficient to meet the enrollee's needs, as required by Medicare guidelines. .  
 
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 custom fabricated wheelchair back 
cushion, replacement arm pads, back frame, back post, and back upholstery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the E2617 exceeds the patient's medical needs. The documentation does not reveal the patient 
has fixed deformities. There is no documentation from a provider without financial relationship with the 
supplier with clear rationale as to why a prefabricated seating system is not sufficient to meet the patient's 
seating and positioning needs. Our reviewer found that the replacement arm pads (K0019) exceeds the patient's 
medical needs as there is no evidence that the patient requires replacement arm pads at this time of initial issue. 
Arm pads are also included in the requested power wheelchair base. Our physician reviewer also found that the 
back frame (K0108), back post (K0108), and back upholstery (K0108) exceed the patient's medical needs as 
the requested power wheelchair comes with arm pads, frame, and base.  
 
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 custom fabricated wheelchair back cushion, replacement arm pads, back 
frame, back post, and back upholstery have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a custom fabricated wheelchair back cushion (E2617), replacement arm pads (K0019), back frame 
(K0108), back post (K0108), and back upholstery (K0108).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A0427 and A0425 billed for date of service 
April 11, 2023. 
 
You asked the Plan to pay for procedure codes A0427 and A0425. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the billed codes are a statutory 
exclusion. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A0427 and A0425 has a Status Indicator of X on the Physician Fee Schedule. This 
means that procedure code A0427 and A0425 is a statutory exclusion. Based on this information, we decided 
that Medicare rules for coverage of procedure codes A0427 and A0425 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes A0427 and A0425 billed for date of service 
April 11, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided on August 4, 2023, to August 
16, 2023, by an OON provider.  
 
You asked the Plan to pay for the psychotherapy. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was 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 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 psychotherapy provided on August 4, 2023, to 
August 16, 2023, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ultrasounds provided on May 04, 2023. 
 
You asked the Plan to reduce the copayment for the ultrasounds. You say that you were unaware the provider 
was out-of-network. 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 $160 
copayment for out-of-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $160 copayment for the ultrasounds. This item/service falls within the out-of-
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 ultrasounds provided on May 04, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on April 
20, 2023. 
 
You asked the Plan to reduce the copayment for the specialist office visit. You say that you should only be 
charged a $20 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 $50 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $50 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 specialist office visit provided on April 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99231 billed for date of service June 13, 
2023.  
 
You asked the Plan to pay for procedure code 99231. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99231 is bundled into payment for code 
00670. 
 
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, we have confirmed that code 99231 is a column two code to column one code 00670 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99231 billed for date of service June 13, 2023.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the to waive for the ambulance services provided on June 25, 2023.

You asked the Plan to waive the copayment for ambulance services. You say that the ambulance misdirected you. 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 $200 copayment for the ambulance services.

You have been asked to pay a $200 copayment for the ambulance services. This item/service falls within the ambulance 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 ambulance services provided on June 25, 2023
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 22, 2022, billed with 
codes 81162, 81201, 81209, 81218, 81292, 81295, 81307, 81314, 81317, 81321, 81334, 81351, 81406, 81437, 
81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have submitted medical records to 
substantiate medical necessity for the services performed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 22, 2022, billed with codes 81162, 81201, 81209, 81218, 81292, 81295, 81307, 81314, 81317, 81321, 
81334, 81351, 81406, 81437, 81479.