Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 14, 2020 to April 
16, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that you were directed to be evaluated by a physician 
who ordered these tests. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network 
with the Plan. 
 
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 has network providers 
available who can provide 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 medical services provided on March 14, 2020 
to April 16, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a psychiatric diagnostic evaluation. 
 
You asked the Plan to pre-approve a psychiatric diagnostic evaluation. You say that the enrollee has been under 
the care of this physician for 13 years and is comfortable with this physician. You say he cannot easily adapt to 
changes in routine because he has Autism Spectrum Disorder. The Plan denied your request. The Plan says out 
of network services are not approved unless they are not available in network or are emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested psychiatric diagnostic evaluation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for arthroscopic extensive shoulder debridement (29823-AS, 59, LT) subacromial decompression (29826-AS, 59 LT) Arthroscopic rotator cuff repair (29827-AS, LT) provided December 26, 2019.
You asked the Plan to pay for the surgical assistant services. You say that you bill services as directed by the surgeon's office. This charge was for the surgical assistant. The Plan denied your request. The Plan says surgical technicians are not listed as a health care practitioner that can report modifier AS. The services of a surgical technician assisting at surgery are included in the reimbursement to the facility and not separately reimbursable.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. You provided surgical assistant services. The services of a surgical technician assisting at surgery are included in the reimbursement to the facility and not separately reimburseable. Payment to you for this service is the responsibility of the facility or hospital.
Therefore, we decided that the Plan does not have to pay for arthroscopic extensive shoulder debridement (29823-AS, 59, LT) subacromial decompression (29826-AS, 59 LT) Arthroscopic rotator cuff repair (29827-AS, LT) provided December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital visit provided on April 3, 2020. 
 
You asked the Plan to pay for the subsequent hospital visit. You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says this service is included in the global surgical fee and not separately 
payable. 
 
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 the 
99231 has a global relationship with code 36558 and cannot be paid as billed. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the 
subsequent hospital visit provided on April 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist office visit to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve specialist office visit. You say that you cannot find any in-network 
providers available. The Plan denied your request. The Plan says there are in-network providers available for 
these services, 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
specialist office visit to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0823) and accessories (E2365, 
K0195). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you returned your 
previous wheelchair. The Plan denied your request. The Plan says you previously received a power wheelchair 
in January. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power wheelchair. a power wheelchair serves the same purpose as a power 
wheelchair and accessories. No documentation has been submitted to demonstrate why your power wheelchair 
should be replaced. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair 
(K0823) and accessories (E2365, K0195).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the denture reline services rendered on April 17, 2019. 
 
You asked the Plan to pay for these services. You say that you were told you would only owe $7,700 for the 
services. The Plan denied your request. The Plan says the services are not covered. 
 
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. 
 
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 the 
denture reline services rendered on April 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant (D6010) for posterior 
tooth #19.  
 
You asked the Plan to pre-approve the surgical placement of implant (D6010). You say that it was necessary to 
have the tooth extracted as quickly as possible. You say that complications from tooth infections are an 
unnecessary risk. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, coverage for implants is limited to 
single missing anterior teeth. Tooth #19 is a posterior tooth, which is not a covered benefit. Therefore, we 
decided that the Plan does not have to pre-approve the surgical placement of implant (D6010) for posterior 
tooth #19.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 
13, 2019. 
 
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 records do not support the services billed. 
 
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 80159: 
 
Clozapine 
 
CPT 80162: 
 
Digoxin; total 
 
CPT 80173: 
 
Haloperidol 
 
CPT 80201: 
 
Topiramate 
 
 
We find that the denied codes are not supported in the medical record. Specifically, there is no valid physician 
order for these services, and the services were done by urine sampling rather than blood sampling. Therefore, 
we decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 
13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on May 23, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and 
approved for payment. You say that these services were provided in a skilled nursing facility. The Plan denied 
your request. The Plan says prior authorization was not obtained for these services. 
 
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 has network providers 
available who can provide 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 skilled nursing services provided on May 23, 2019 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lower immediate denture (D5130) and bone 
replacement graft (D7953). 
 
You asked the Plan to pre-approve the lower immediate denture (D5130) and bone replacement graft (D7953). 
You say that when the teeth are removed, a denture will be needed. You say that the enrollee cannot afford 
many things. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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. 
 
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 the 
lower immediate denture (D5130) and bone replacement graft (D7953).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on December 19, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that testing to confirm that a urine specimen is 
unadulterated is an internal control process that is not separately reportable. 
 
We looked at the file and Medicare rules. The file shows that the tests at issue were urine specimens utilized for 
drug testing. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on 
December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the provisional crown for tooth #31.
You asked the Plan to pre-approve the provisional crown for tooth #31. 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 Plan's 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 records show that the Plan pre-approved a permanent crown for
tooth #31. Therefore, we decided that the Plan does not have to pre-approve the provisional crown for tooth
#31.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcatheter aortic valve replacement (TAVR) rendered 
on January 14, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The rules say that TAVR is covered for uses that are not expressly listed as an FDA-approved indication when 
performed within a clinical study that fulfills all required criteria. 
 
We looked at the file and Medicare rules. The file shows that the TAVR was rendered in the setting of a 
clinical trial but was not billed with a valid clinical trial number. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the transcatheter aortic valve replacement (TAVR) rendered on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on February 7, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this
service is included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers. Payment for all fees related to this service would have been included under the facility claim.
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on February 7,
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0428) received 
on April 1, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were informed by a 
representative of the hospital that you would receive ambulance services at no charge. The Plan denied your 
request. The Plan says you were charged this cost sharing 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 $250 
copayment for each ambulance trip. You had 1 ambulance trip. The Plan charged you $250 for 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 the ambulance services (A0428) received on April 1, 2020.  
 
Your complaint about being given erroneous or misleading information by a representative of the hospital is 
not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on February 5, 2020 to 
February 8, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 has network providers 
available who can provide 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 home health services provided on February 5, 
2020 to February 8, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper and lower denture. 
 
You asked the Plan to pre-approve the complete upper and lower denture. You say that you only received 
partial dentures in 2017. You say that you are unable to use the partials and are requesting complete dentures. 
The Plan denied your request. The Plan says the service is limited to once every 60 months. 
 
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, you also have a maximum benefit of 
one partial, full or immediate denture every 5 years. The Plan says that you received complete dentures on 
March 19, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-
approve the complete upper and lower denture.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous decompression laminotomy (0275T). 
 
You asked the Plan to pre-approve percutaneous decompression laminotomy. You say that based on the 
information provided in this appeal request, you would like an expedited review of this denial on behalf of the 
enrollee. The Plan denied your request. The Plan says the Medicare criteria listed in the NCD has not been met. 
 
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 percutaneous decompression 
laminotomy. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the medical records provided  do not meet the 
requirements listed in the National Coverage Determination (NCD) for Percutaneous Image-Guided Lumbar 
Decompression for Lumbar Spinal Stenosis (150.13) as the records do not indicate that the enrollee is enrolled 
in an approved clinical study. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous decompression laminotomy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve percutaneous decompression laminotomy (0275T).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sleep study, unattended, simultaneous recording; heart 
rate, oxygen saturation, respiratory analysis (e.g., by airflow or peripheral arterial tone), and sleep time. 
 
You asked the Plan to pre-approve a sleep study (95800). You say that the enrollee wakes up tired and has 
depression. The Plan denied your request. The Plan says minimal clinical data was provided. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The record does not show the sleep study is for prescribing a CPAP. 
Based on this information, we decided that Medicare rules for coverage of a sleep study (95800) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve Sleep study, unattended, simultaneous 
recording; heart rate, oxygen saturation, respiratory analysis (e.g., by airflow or peripheral arterial tone), and 
sleep time.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup. 
 
You asked the Plan to pre-approve the core buildup. You say that the enrollee has a large amalgam filling with 
recurrent decay. You say that a full crown is required for proper support. 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 Plan?s 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 the 
core buildup.