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

 
We decided that the Plan does not have to pay for physician's services provided on September 2, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 and the referring provider are not network providers with the Plan. The Plan 
did not pre-approve the physician?s services. 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 physician's services provided on 
September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on August 5, 2020 by an out-of-network provider.

You asked the Plan to pay for the vision services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care.

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 these services when provided by a Plan network provider.

We looked at the file and the Plan's rules.  The file shows that the provider who provided the vision services is not a Plan network provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the vision services provided on August 5, 2020 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardio screening provided on April 23, 2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare 
denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic 
patients. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
We looked at the file and the rules. The testing at issue in this appeal was requested for screening purposes. 
There is no Medicare benefit for the testing services for asymptomatic patients. Screening asymptomatic 
patients for cardiovascular risk is statutorily excluded by Medicare. Therefore, we decided that the Plan does 
not have to pay for the hereditary cardio screening provided on April 23, 2020.
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 you have a broken femur and needed to receive 
blood. You say that you have a brand-new hip and cannot be left alone. The Plan denied your request. The Plan 
says the clinical information provided does not support that the criteria for coverage of IRF care have been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 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 
was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical conditions are stable. There 
are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There 
is not a reasonable expectation that the 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 7, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The laboratory services at issue in this appeal were requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on July 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral exam (D0150) provided September 8, 2020.

You asked the Plan to pay for the dental services. You say that you saw a dentist in October 2019 and was very uncomfortable. You started having problems with your teeth and made an appointment with another dentist and feel this could have been prevented. The Plan denied your request. The Plan says this service exceeds the frequency limitation.

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 health plan contract says that this service is allowed once every 3 years. The records show this service was provided October 8, 2019.

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 comprehensive oral exam (D0150) provided September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TDAP vaccine (90471, 90715) administered on July 24, 
2020. 
 
You asked the Plan to pay for the TDAP vaccine. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this is not a Medicare covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the TDAP vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the TDAP vaccine. 
Therefore, we decided that the Plan does not have to pay for the TDAP vaccine (90471, 90715) administered 
on July 24, 2020.  
 
Benefits for the TDAP vaccine may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D7270) received on August 10, 2020. 
 
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 Medicare does not cover replacement of teeth. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services (D7270) received 
on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ophthalmology visits to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON ophthalmology visits. You say that this is the only provider that does 
eye injections. The Plan denied your request. The Plan says eye injections and other ophthalmology services 
are available in-network. Please note that the Plan has indicated that they have approved two visits with the 
out-of-network provider to allow for a smooth transition of care. 
 
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 
the ophthalmology visits to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services with dental codes D9215, D2980, D6750, 
D6240, and D1999 provided on August 17, 2020. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says dental codes D9215, D2980, D6750, D6240, 
and D1999 are not covered under the Plan's supplemental dental 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, dental codes D9215, D2980, D6750, 
D6240, and D1999 are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for the dental services with dental codes D9215, D2980, D6750, D6240, and D1999 provided 
on August 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Oncology (prostate) gene expression profile with CPT 
code 0005U provided on June 3, 2020. 
 
You asked the Plan to pay for CPT code 0005U. 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Medicare specifically says that CPT code 0005U is not covered. 
Therefore, we decided that the Plan does not have to pay for the Oncology (prostate) gene expression profile 
with CPT code 0005U provided on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services with CPT code 88332 provided on 
March 18, 2020. 
 
You asked the Plan to pay for CPT code 88332. 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 as 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, we have confirmed that code 88332 
has a bundled relationship with code 88331 and cannot be paid as billed. This code cannot be paid as a separate 
line item. 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 pathology services with CPT code 88332 provided on March 18, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) 
rendered by the out of network (OON) provider on July 13, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out of network 
(OON) provider on July 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's underlying medical conditions do not require close medical supervision or 
titration of self-administered medications. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 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 
was admitted for a pelvic fracture after a fall. Medical conditions are stable. There are no medical needs 
requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 the enrollee was admitted for left above the knee amputation and CoViD-19 
infection. The enrollee's medical conditions are stable. The documentation does not support that the enrollee 
requires an interdisciplinary approach to rehabilitation care. While the documentation shows a need for 
physical therapy and occupational therapy, the documentation does not support that the enrollee requires an 
intensive rehabilitation therapy program. The enrollee's care needs can be met at lower level of care. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Oncology (prostate) gene expression profile with CPT 
code 0005U provided on June 26, 2020. 
 
You asked the Plan to pay for CPT code 0005U. 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 as 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. 
 
We looked at the file and Medicare rules. Medicare rules specifically say that CPT code 0005U is not covered. 
Therefore, we decided that the Plan does not have to pay for the Oncology (prostate) gene expression profile 
with CPT code 0005U provided on June 26, 2020.
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 this is medically necessary because you are unable to 
function. The Plan denied your request. The Plan says your needs could be met in a different setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for an 
infection of the foot and subsequent partial amputation of the foot. Your medical conditions are stable. There 
are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You 
do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that you 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 waive the coinsurance for the extractions (D7140 and D7210) and 
pay for the partial denture (D5222) provided on July 30, 2020. 
 
You asked the Plan to waive the coinsurance for the extractions (D7140 and D7210) and pay for the partial 
denture. You say that you would like reconsideration because these services are necessary for your overall 
health. The Plan denied your request. The Plan says the correct coinsurance has been applied for the extractions 
and the partial denture is a non-covered service. 
 
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% 
coinsurance for dental services.  
 
You have been asked to pay a 50% coinsurance for the extractions. The extractions fall within the dental 
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. Additionally, per the EOC CPT code D5222 is not a covered service. Therefore, we decided that the Plan 
does not have to waive the coinsurance for the extractions (D7140 and D7210) and pay for the partial denture 
(D5222) provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 19, 
2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
a prior authorization is required for out-of-network services that are not urgent or 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 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 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 subsequent nursing facility care provided on August 19, 2020.