Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided on 
August 2, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the psychotherapy services . You say that you have enclosed the supporting 
medical records to prove the need for the services rendered to be paid to the provider of service. 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 individual psychotherapy services (90832) provided on August 2, 2023, by an out-of-network (OON) 
provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on September 02, 2023, 
to September 05, 2023. 
 
You asked the Plan to waive the copayment for ER visit. You say that pain in is you had pain in your left leg 
and a possible leg clot that could have led to a stroke. 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 $90 
copayment for Emergency care. 
 
You have been asked to pay a $90 copayment for ER visit. This item/service falls within the Emergency 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 ER visit provided on September 
02, 2023, to September 05, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on July 24, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
documents needed for payment. The Plan denied your request. The Plan says the documentation requirements 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on July 24, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance services provided on June 27, 2023. 
 
You asked the Plan to pay for the air ambulance services. You say that the services were an emergency and 
prior authorization was not required. The Plan denied your request. The Plan says the information received 
does not support the criteria for air transport.  
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the air ambulance services were not medically necessary. Our physician reviewer found the 
documentation does support that the enrollee suffered from an illness or injury that contraindicated 
transportation by any means other than ambulance as they required drip medications and transfusion. The 
documentation, however, does not support that the enrollee's condition was such that the time needed to 
transport by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or 
seriously endangered their health. There were closer facilities with gastroenterology with the same or less time 
to travel by ground transport than the air transport to the receiving hospital. The documentation also did not 
clearly support that the transferring hospital did not have adequate facilities to provide the medical services 
needed by the enrollee as there was no indication the hospital did not have access to a gastroenterology 
specialist or an intensive care unit.  
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for the air ambulance services provided on June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve collection and application of autologous blood 
concentrate (D7921). 
 
You asked the Plan to pre-approve collection and application of autologous blood concentrate. You say that 
this should be covered. The Plan denied your request. The Plan says this is not a covered 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. Therefore, we decided that the Plan does not have to pre-approve 
collection and application of autologous blood concentrate (D7921).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for computed tomography (CT) scans, and injections 
provided from July 5, 2023, to July 9, 2023. 
 
You asked the Plan to waive the cost for CT scans and injections. You say that you feel you should not owe 
these costs. 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 $180 
copayment and a $165 copayment for advanced imaging services, a $15 copayment for basic radiological 
services, and a 20% coinsurance for Medicare Part B prescription drugs.  
 
 You have been asked to pay $426.06 total cost for CT scans and injections ($180 + $165 + $15 + $66.03 = 
$426.06). This item/service falls within the advanced imaging services, basic radiological services, and 
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. Therefore, we decided that the Plan does not have to waive the cost for 
computed tomography (CT) scans, and injections provided from July 5, 2023, to July 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on August 01, 2023. 
 
You asked the Plan to pay for the lab testing. You say that you are requesting reconsideration for the service 
provided. 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 lab testing provided on August 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 98940 and 97530 provided on September 
20, 2023. 
 
You asked the Plan to pay for procedure codes 98940 and 97530. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 rules also say that providers must comply with 
ICD-10-CM coding guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 
note which lists other diagnosis codes with which they cannot be reported. The rules also say that plans can 
require enrollees to get care from network providers. 
 
The records show that procedure code 97530 is not manual manipulation of the spine. Additionally, we have 
confirmed that M54.2 has an Excludes1 note in relation to M50.20 billed with procedure code 98940. This 
means that the two diagnosis codes cannot be reported together. Lastly, 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. Therefore, we decided that the Plan does not have to pay for procedure 
codes 98940 and 97530 provided on September 20, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on July 20, 2023. 
 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 documents do not support this level of care. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making." 
 
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 the enrollee presented to the 
emergency department (ED) with dizziness/room spinning, tremors, weakness, nausea and vomiting. The vitals 
were stable. Following an unremarkable workup, vertigo was diagnosed. The enrollee was treated with 
medicine, ondansetron, and oral fluids, which were tolerated, and was sent home. The provided documentation 
included an appropriate history and examination; however, it does not support medical decision-making of high 
complexity to justify CPT 99285.  
 
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 emergency room services (procedure code 99285) rendered on July 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets Medicare criteria for this request, 
and the enrollee's need cannot be met at a lower level of care. The Plan denied your request. The Plan says that 
the enrollee does not meet Medicare guidelines for IRF admission.  
 
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 that 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. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
 and benefit from  the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on September 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $2,000 annual maximum 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 $2,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on September 18, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the analysis of a neurostimulator generator 
provided on August 31, 2023. 
 
You asked the Plan to waive the copayment for the analysis of a neurostimulator generator. 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 $150 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $150 copayment for the analysis of a neurostimulator generator. 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. However, since the 
allowed amount is less than the standard copayment, you only owe $107.53. Therefore, we decided that the 
Plan does not have to waive the copayment for the analysis of a neurostimulator generator provided on August 
31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alveoloplasty in conjunction with extractions (D7310) 
provided on April 5, 2023. 
 
You asked the Plan to pay for alveoloplasty in conjunction with extractions. You say that you are appealing 
with supporting records. 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 
alveoloplasty in conjunction with extractions (D7310) provided on April 5, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9338 billed for dates of service May 30, 
2023, to August 15, 2023. 
 
You asked the Plan to pay for procedure code S9338. You say that this needs to be reprocessed under DME 
guidelines. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 S9338 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9338 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9338 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9338 billed for dates of service May 30, 2023, to August 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the debridement procedures provided on 
May 26, 2023, and May 30, 2023. 
 
You asked the Plan to waive the copayments for the debridement procedures. You say that you disagree with 
the copayments. 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 $275 
copay for each Medicare-covered outpatient surgery at an outpatient hospital facility.  
 
 
 You have been asked to pay $166.31, which is less than the standard copayment for the debridement procedure 
provided on May 26, 2023. You have also been asked to pay $108.69, which is less than the standard 
copayment for the debridement procedure provided on May 30, 2023. These items/services fall within the 
outpatient surgery, including services provided at hospital outpatient facilities 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 copayments for the debridement procedures provided on May 26, 2023, and May 
30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic x-ray (D0330) and limited oral evaluation 
(D0140) provided on August 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that you needed to follow 
any frequency on having the dental procedure. You also say that no one told you about it. The Plan denied your 
request. The Plan says your benefit for the requested item or 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 panoramic x-ray (D0330) and limited oral evaluation (D0140) were exhausted on date 
of service July 14, 2023. Therefore, we decided that the Plan does not have to pay for panoramic x-ray (D0330) 
and limited oral evaluation (D0140) provided on August 29, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the polarization (V2762 x2) and progressive lenses (V2781 x2) 
provided on May 5, 2023. 
 
You asked the Plan to pay for the lens upgrades. You say that you were told that you would have no member 
responsibility, and everything would be covered by the Plan. You also say that you were unaware that 
additional services added to lenses would not be covered, and you were not told by the provider. The Plan 
denied your request. The Plan says that you are responsible for the copays on the upgrades to the lenses. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $200 single-purchase annual eyewear allowance through a Plan-approved Vision 
provider. 
 
We looked at the file and the Plan's rules. The record does not show that your $200 allowance has been met. 
The 2023 Evidence of Coverage does not clearly state which lens types are covered or which lens types are not 
covered by the Plan. You reasonably believed these lenses would be covered. Based on this information, we 
decided that the Plan's rules for coverage of the lens upgrades have been met. Therefore, we decided that the 
Plan has to pay for the polarization (V2762 x2) and progressive lenses (V2781 x2) provided on May 5, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.