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

We decided that the Plan does not have to pay for the IDH2 common variants (81121),IDH1 common variants 
(81120), androgen receptor gene analysis of full sequence (81173) and adenomatous polyposis coli gene 
analysis of full sequence (81201) provided on October 14, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you provided medically necessary services 
referred by another provider. The Plan denied your request. The Plan says prior authorization must be obtained 
for non-emergent services rendered by an out-of-network provider. 
 
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 IDH2 common variants (81121),IDH1 
common variants (81120), androgen receptor gene analysis of full sequence (81173) and adenomatous 
polyposis coli gene analysis of full sequence (81201) provided on October 14, 2019 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 periodontal maintenance (D4910), gingival irrigation 
(D4921 x 4), topical application of fluoride varnish (D1206), and drugs and medicaments (D9630 x 2) provided 
on February 17, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were not made aware that the provider did 
not accept your insurance. You say that the dental office did not inquire about changes to your insurance. You 
also say that you were not advised until after your appointment that your dentist was no longer at that office. 
The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says 
that you must receive preventive dental services from a participating network provider. 
 
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 services that you receive out of 
network are not covered. Therefore, we decided that the Plan does not have to pay for the periodontal 
maintenance (D4910), gingival irrigation (D4921 x 4), topical application of fluoride varnish (D1206), and 
drugs and medicaments (D9630 x 2) provided on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
January 8, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that medically necessary services were rendered in 
good faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
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 subsequent nursing facility care (99308) 
provided on January 8, 2020 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 an emergency room visit provided by a 
participating provider on March 30, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you had to go to the ER 
because of Covid-19 and not the eye doctor. You say that you feel like this copayment should be waived. The 
Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 an emergency room visit. An emergency room visit 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 an 
emergency room visit provided by a participating provider on March 30, 2020.  
 
We note your complaint about having to go to the emergency room because of Covid-19. Your complaint is a 
grievance that must be answered by the health plan. Medicare does not permit us to make a decision about 
these types of complaints.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department services, provided on February 
21, 2020, at a high complexity level. 
 
You asked the Plan to pay for the emergency department services (99285). You say that the Plan should pay 
this claim at the high complexity level. The Plan denied your request. The Plan says the records do not support 
a high complexity level of service therefore the claim was down-coded to 99284. 
 
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 these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, the medical records provided 
do not sufficiently support the billing of code 99285 as it appears further evaluations and surgical consults were 
to be performed once the enrollee was admitted as inpatient. Based on this information, we decided that 
Medicare rules for coverage of the emergency department services (99285) have not been met. Therefore, we 
decided that the Plan does not have to pay for the emergency department services, provided on February 21, 
2020, at a high complexity level.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic parenteral drug (D9610) provided on June 1, 
2020. 
 
You asked the Plan to pay for the therapeutic parenteral drug. You say that the use of a local anesthetic alone 
was an impossible situation. You also say that these services were needed in order to provide the appropriate 
management. The Plan denied your request. The Plan says this service is not a covered benefit under your 
dental plan. 
 
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 
therapeutic parenteral drug (D9610) provided on June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown, core buildup and periodontal scaling and root 
planing provided on June 26, 2020. 
 
You asked the Plan to pay for the crown, core buildup and periodontal scaling and root planing. You say that 
you were told you had $850 for dental work on the current plan. You say that the Plan should make good on 
this issue. The Plan denied your request. The Plan says you have already received the maximum amount of 
coverage allowed. 
 
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 also had an annual allowance of 
$100. The Plan paid $100 to fully cover the limited oral evaluation, intraoral x-ray and unspecified periodontal 
procedure provided on June 24, 2020, and June 26, 2020, which exhausted your benefit. Therefore, we decided 
that the Plan does not have to pay for the crown, core buildup and periodontal scaling and root planing 
provided on June 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 25, 
2020, to May 26, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the 
notes did not show that the enrollee failed a trial of observation care first. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights.  
 
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 acute inpatient hospital care. Our physician 
reviewer found that the enrollee was brought to the emergency room with mental status changes and a blood 
glucose of 38. The exam revealed confusion and rhonchi. The chest x-ray was normal, and the EKG was sinus 
bradycardia without any acute ischemic changes. She continued treatment with IV fluids and IV Rocephin. Her 
condition stabilized and improved and she was discharged home. The record did not show that at the time of 
inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care 
(including earlier ED and/or observation care) would span two midnights. Therefore, the provided inpatient 
services were not medically reasonable or 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from May 25, 2020, to May 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion/specialty drug administration services 
coded 99601 and 99602 provided on December 10, 2019. 
 
You asked the Plan to pay for the home infusion/specialty drug administration services. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 
are not 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. 
 
We find that CPT codes 99601 and 99602 are not supported in the medical record. Specifically, these codes 
have a status code of "I". A status code of I means that these services are not valid for Medicare purposes. 
Medicare uses another code for reporting of, and payment of these services. Based on this information, we 
decided that Medicare rules for coverage of the home infusion/specialty drug administration services have not 
been met. Therefore, we decided that the Plan does not have to pay for the home infusion/specialty drug 
administration services coded 99601 and 99602 provided on December 10, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 1, 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 testing at issue in this appeal was 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 May 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the wound care debridement provided from 
March 3, 2020, to March 24, 2020. 
 
You asked the Plan to waive the copayment for the wound care debridement. You say that you were never in a 
hospital so should not be charged as an outpatient and you are on a fixed income and cannot afford the 
copayments. The Plan denied your request. The Plan says you were charged the copayments 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 $350 
copayment for Hospital Outpatient Facilities and Ambulatory Surgical Centers.  
 
You have been asked to pay a $350 copayment for each wound care debridement service. The wound care 
debridement falls within the Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the wound care debridement provided from March 3, 2020, 
to March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sixty minutes of psychotherapy (90837) to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve psychotherapy. You say that the services are medically necessary. The Plan 
denied your request. The Plan says this provider does not accept payment from any health insurance providers, 
therefore the requested provider is not a Medicare provider. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the record indicates that the provider at issue was 
not enrolled with Medicare for the date of service at issue. There was no documentation to verify the provider's 
enrollment in Medicare for the date of service at issue. Therefore, we decided that the Plan does not have to 
pre-approve the sixty minutes of psychotherapy (90837) to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left knee arthroscopy and partial lateral meniscectomy. 
 
You asked the Plan to pre-approve left knee arthroscopy and partial lateral meniscectomy. You say that the 
requested left knee arthroscopy and partial lateral meniscectomy is medically necessary. The Plan denied your 
request. The Plan says the requested left knee arthroscopy and partial lateral meniscectomy is not medically 
necessary. 
 
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 left knee arthroscopy and partial lateral 
meniscectomy. Our reviewer says that the requested left knee arthroscopy and partial lateral meniscectomy is 
not medically necessary. Our physician reviewer found the enrollee is with a diagnosis of grade 2-3 
osteoarthritis of the knee. The images show advanced degenerative joint disease. Criteria for cartilage repair 
have not been met. Surgery is not medically needed at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of left knee arthroscopy and partial lateral meniscectomy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve left knee arthroscopy and partial lateral 
meniscectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99244) provided from November 27, 2019. 
 
You asked the Plan to pay for an office visit. You say that this code is supported. The Plan denied your request. 
The Plan says this code is not valid for Medicare. 
 
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 find that CPT code 99244 is not supported in the medical record. Specifically, this code has a status 
indicator of "I". Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we 
decided that the Plan does not have to pay for an office visit (99244) provided from November 27, 2019.
Appeal type: Outpatient Mental Health
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 March 16, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
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 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 March 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the new patient office or other outpatient visit with 
electrocardiogram (99203, 93000) provided on February 25, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the new patient office or other outpatient visit with electrocardiogram. 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 by the facility or the provider; therefore, payment has been correctly 
denied. 
 
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 new patient office or other outpatient visit with 
electrocardiogram (99203, 93000) provided on February 25, 2020, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee braces with suspension sleeves provided on 
December 26, 2019. 
 
You asked the Plan to pay for the knee braces. You say that the documentation supports that this should be 
paid. The Plan denied your request. The Plan says the proof of delivery documentation provided is not adequate 
to verify that deliver was made. 
 
The Plan must follow Medicare rules. Medicare rules say that knee braces are covered when the above criteria 
are met, and provider must submit documentation to confirm that Medicare coverage criteria have been met. 
 
In this case, the proof of delivery documentation is valid and is not an appropriate denial reason. However, the 
order form signature does not appear to match the signature from the medical records. Moreover, the records 
provided do not include a progress note from prior to the date which the order was signed, and the progress 
note makes no mention of knee pain, instability, or a recent injury or surgery. Based on this information, the 
documentation does not support that Medicare criteria for these items have been met. Therefore, we decided 
that the Plan does not have to pay for the knee braces with suspension sleeves provided on December 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture and complete mandibular 
denture provided on May 11, 2020 by an OON provider. 
 
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that 
you needed the dentures because you had been without teeth for about 7 months, and this provider was the only 
one you could find who would see you. The Plan denied your request. The Plan says these services were 
rendered by a non-contracted provider. The Plan also says that no benefits are available for procedures 
performed by OON providers. 
 
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 
complete maxillary denture and complete mandibular denture provided on May 11, 2020 by an OON provider.