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

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on May 4, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on May 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab tests provided on April 27, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab tests. 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. The Plan says that 
the member's primary care physician did not refer 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 lab tests provided on April 27, 2020 by an out of 
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to fully pay for the periodic oral evaluation (D0120), vertical bitewing 
x-rays (D0277), and periodontal maintenance (D4910) provided on February 27, 2020 by an OON provider. 
 
You asked the Plan to fully pay for the periodic oral evaluation, vertical bitewing x-rays, and periodontal 
maintenance. You say that you understand that you have dental coverage, in-network or out-of-network. The 
Plan denied your request. The Plan says the OON liability was applied correctly per your plan benefits. The 
Plan also says that the Plan pays according to a maximum allowable fee schedule, and you are responsible for 
all fees in excess of this amount from the billed amount. 
 
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, you are responsible for the difference 
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to fully pay 
for the periodic oral evaluation (D0120), vertical bitewing x-rays (D0277), and periodontal maintenance 
(D4910) provided on February 27, 2020 by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from March 27, 2020 to 
April 25, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
 
 
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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from March 27, 2020 to April 25, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia for electrical conversion of arrhythmias provided on 
March 31, 2020. 
 
You asked the Plan to pay for the anesthesia services. You say that these services were rendered and billed 
correctly and should not be bundled with any other procedure. The Plan denied your request. The Plan says that 
this cannot be paid since the facility reported as the facility reported a procedure was discontinued prior to 
anesthesia being provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. This claim was denied based on the fact that the facility billed code 93312 (for a 
transesophageal echocardiogram) with modifier -73 which means that the procedure was discontinued prior to 
induction of anesthesia. The Plan states that this means that the anesthesia services billed are not payable. 
However, on the same facility claim, code 92960 (electrical cardioversion) was also billed with no modifier to 
show discontinuation. The anesthesia code reported is specifically for the anesthesia necessary for an electrical 
cardioversion. The provider also submitted medical records showing clearly that anesthesia was indeed 
provided. The fact that another distinct procedure was discontinued the same day does not preclude payment 
for the anesthesia for the completed procedure. As such, we find the denial of payment in this case is not 
supported. Therefore, we decided that the Plan has to pay for the anesthesia for electrical conversion of 
arrhythmias provided on March 31, 2020.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a bone density scan (77081) provided January 28, 2020. 
 
You asked the Plan to pay for the bone density scan. You say that the bone scan was medically necessary. The 
Plan denied your request. The Plan says that bone scans are only covered once every 24 months and the 
enrollee already received a bone density scan. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 pay for the bone density scan. Our reviewer says 
that the scan was medically necessary. Our physician reviewer found the enrollee suffers from recurrent 
fractures. The additional bone scan will quantify bone loss to help explain the cause of recurrent fractures. The 
Evidence of Coverage states that bone scans can be covered more frequently than once every 24 months when 
it is 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 the bone density scan have been met. Therefore, we decided that the Plan has to 
pay for a bone density scan (77081) provided January 28, 2020.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays provided on June 17, 2020. 
 
You asked the Plan to pay for the bitewing x-rays. You say that you feel that the x-ray should be covered 
because the dentist had to perform an emergency service for an infected tooth. The Plan denied your request. 
The Plan says your benefit limits had been exceeded for the bitewing x-rays. 
 
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, dental x-rays including bitewing, 
periapical, occlusal, panoramic, or complete series, and are limited to 1, 2, or 4 every 1 or 3 years. The record 
shows that you received bitewing x-rays on September 11, 2019, and your bitewing x-rays benefit was then 
exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays provided on June 
17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on April 
22, 2020. 
 
You asked the Plan to pay for the orthosis. You say that this was medically necessary. The Plan denied your 
request. The Plan says that the submitted office visit notes do not indicate anything regarding an order or any 
type of need for Mobility Braces. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. 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 the lumbar sacral orthosis 
provided to the enrollee on April 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on February 20, 2020. 
 
You asked the Plan to pay for the services provided. You say that anesthesia was required for the procedure to 
make it more comfortable and reduce pain. The Plan denied your request. The Plan says the documentation did 
not clearly establish the need for sedation. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services provided. Our physician 
reviewer found that the enrollee has a history of chronic cervical and low back pain. She had been treated with 
medications, physical therapy, implantation of a spinal cord stimulator, and previous cervical trigger point 
injections. In this case, the enrollee had no significant past medical history to warrant monitored anesthesia 
care (MAC). There was no documentation in the record indicating that it was medically necessary to have an 
anesthesiologist present during the trigger point injections. Medical necessity for an anesthesiologist to 
administer MAC/IV sedation was not established. The review determined that the records did not show that the 
anesthesia services were medically necessary during the enrollee's trigger point injections. 
 
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 provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia services provided on February 20, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from April 21, 2020 to 
May 12, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that having therapy was a crucial part of 
your recovery. The Plan denied your request. The Plan says there was no documentation to support medical 
necessity for a skilled level of care during the time period in question. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 skilled nursing services. Our reviewer 
says that you did not meet the Medicare criteria for SNF care. Our physician reviewer found you did not have 
daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. Our reviewer found that you did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also found that you 
did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
 
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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from April 21, 2020 to May 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and personal 
protective equipment provided on June 22, 2020 by you, an OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and personal protective equipment. 
You say that this enrollee has been a patient of yours for 20 years. You also say that the enrollee obtained a 
new insurance plan, was informed that he must be seen elsewhere, and you believe that is very wrong. The Plan 
denied your request. The Plan says you are not a participating provider with the enrollee's plan. The Plan also 
says that the enrollee is required to receive services from participating providers, or have an approved 
authorization for services with a non-participating provider prior to receiving care. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation, prophylaxis, and personal protective equipment provided on June 22, 2020 by you, an OON 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on May 7, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on May 7, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from February 18, 2020 
to March 14, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist.  
The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from February 18, 2020 to March 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided from November 15, 2019 to 
November 18, 2019. 
 
You asked the Plan to pay for inpatient care. You say that Medicare criteria were met. The Plan denied your 
request. The Plan says the hospital did not coordinate care with the Plan once the enrollee stabilized. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient care. Our reviewer says that the 
criteria for coverage of these services have not been met. Our physician reviewer found the records show that 
the enrollee was stable and appropriate for ambulance transport with monitoring to a Plan facility for 
observation/admission level of care services after the emergency room evaluation on November 15, 2019. The 
post-stabilization care services from November 15, 2019 to November 18, 2019 were not medically necessary 
or reasonable. The review has determined that the treating physician did not document (in the physician notes, 
on a form, or in an order) that the patient was not stable for transfer on any dates of service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient care provided from November 15, 2019 to November 18, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from February 24, 2020 
to March 21, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from February 24, 2020 to March 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (73221, 73030, 73562) on 
January 10, 2020. 
 
You asked the Plan to pay for the magnetic resonance imaging. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services were not pre-authorized or emergent. 
There were network providers available. 
 
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 magnetic resonance imaging (73221, 73030, 
73562) on January 10, 2020.