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

 
We decided that the Plan does not have to pay for the laboratory services (80307 and G0481) provided on July 
9, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you rendered medically necessary services 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 laboratory services (80307 and G0481) 
provided on July 9, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for Vitamin D assay testing provided on January 21, 2020. 
 
You asked the Plan to pay for lab test. You say that you are appealing with records to support medical 
necessity. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, 
because this test is not covered by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
This testing was ordered by an in-network provider. The file does not show that the plan provided notice that 
lab test would not be covered. The Plan cited Local Coverage Determination (LCD) Assays for Vitamins and 
Metabolic Function (L34914) as a non-coverage article for this testing, however this article does not have 
jurisdiction over the geographic location where this testing was performed and therefore does not apply. Under 
Medicare rules, this means lab test is considered approved by the plan. Therefore, we decided that the Plan has 
to pay for Vitamin D assay testing provided on January 21, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ocular implant procedure (65175) 
performed on February 28, 2020. 
 
You asked the Plan to waive the copayment for an ocular implant procedure. You say that this was a correction 
to an earlier procedure and should not be charged to you. The Plan denied your request. The Plan says the 
correct copayment was 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 $95 
copayment for Medicare-covered surgery.  
 
You have been asked to pay a $95 copayment for an ocular implant procedure. An ocular implant procedure 
falls within the "Outpatient Surgery and Other Medical Services Provided at 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 an ocular 
implant procedure (65175) performed on February 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 24, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physicians 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 July 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper denture (D5110). 
 
You asked the Plan to pre-approve the complete upper denture (D5110). You say that you are in a lot of pain 
and can barely keep the denture in your mouth. You say that you need a new pair because it is almost 
impossible to eat anything or speak correctly. The Plan denied your request. The Plan says the service exceeded 
the maximum count allowed per period. 
 
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 complete upper denture every five plan years. The Plan paid for a complete upper denture provided on 
March 26, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-
approve the complete upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network chiropractic services provided on August 2, 
2019. 
 
You asked the Plan to pay for these services. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says you did not have prior authorization for out of network 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 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 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 out of network chiropractic 
services provided on August 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management services (99238) 
provided on October 29, 2019. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not include a hospital discharge day management note for the billed date of service. 
 
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 99238 is hospital discharge day management; 30 minutes 
or less. 
 
We find that CPT code 99238 is not supported in the record. Specifically, the documentation submitted does 
not include a discharge day note to indicate that discharge day services were rendered on the billed date of 
service. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day 
management services have not been met. Therefore, we decided that the Plan does not have to pay for hospital 
discharge day management services (99238) provided on October 29, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission to a SNF. You say that you need SNF care. The Plan denied 
your request. The Plan says admission to a SNF is not medically necessary. 
 
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 pre-approve the admission to a SNF. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found although there are identifiable 
skilled therapy service needs, there are no identifiable skilled nursing service needs. Furthermore, the 
beneficiary does not require skilled nursing or therapy services on a daily basis and does not meet severity of 
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 20, 
2020. 
 
You asked the Plan to pay for the dental service. You say that you were referred to this provider by your 
regular dentist. You say that this was not a routine visit. You also say that you had to have teeth cut out that had 
broken off too low for the dentist to pull. The Plan denied your request. The Plan says 1 limited oral evaluation 
is covered per plan year. The Plan also says that the frequency limit for this service has been exceeded. 
 
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 frequency limit of once per plan 
year has been exceeded. The record shows that the plan paid for this service that you received on June 10, 
2020. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) 
provided on July 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia for a dental alveolar procedure. 
 
You asked the Plan to pre-approve the anesthesia. You say that the enrollee is disabled and unable to tolerate a 
normal dental setting. You say that the enrollee will need general anesthesia. The Plan denied your request. The 
Plan says the service is 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 anesthesia is not covered since the 
main dental procedure is not a covered benefit. Therefore, we decided that the Plan does not have to pre-
approve anesthesia for a dental alveolar procedure.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided to the enrollee from 
January 8, 2020, to January 29, 2020. 
 
You asked the Plan to pay for this service. You say that SNF admission was medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria were not met. 
 
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 this service. Our reviewer says that daily skilled services are not necessary. Our physician reviewer 
found there were no identifiable skilled therapy service needs. The enrollee did not require skilled nursing or 
therapy services daily for the dates in question. Medicare coverage criteria for SNF care were not met. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility services provided to the enrollee from January 8, 2020, to January 29, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation therapy. 
 
You asked the Plan to pre-approve radiation therapy. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records are lacking despite the insurer specifically requesting them. The treatment 
would likely be standard of care, but with no way of knowing what the treatment plan is, a favorable decision 
cannot be made. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiation therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from IRF care to optimize 
level of function. The Plan denied your request. The Plan says rules for IRF care have not 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 that the enrollee does not require the intensity of services provided at an 
IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation. 
 
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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on May 28, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that your husband passed out in a 
grocery store. You say an ambulance was provided because of fear of Covid-19. 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $250 copayment for ambulance services.  
 
The enrollee has been asked to pay a $250 copayment for an ambulance trip. Since an ambulance trip was 
provided, the correct copayment has been applied. An ambulance trip falls within the ambulance services 
benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract 
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapy services to be provided by the requested 
therapist. 
 
You asked the Plan to pre-approve the therapy services. You say that your daughter is being treated by this 
therapist and you need to have therapy with the same provider for anxiety. The Plan denied your request. The 
Plan says this provider not listed on the Medicare website as a therapist who sees Medicare patients. Medicare 
rules require providers to be listed with Medicare for Medicare enrollees to see them. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist (MFT) is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue is a Marriage Family Therapist (MFT).  
Medicare says that a Marriage Family Therapist (MFT) is not eligible to participate in the Medicare program. 
Therefore, we decided that the Plan does not have to pre-approve therapy services to be provided by the 
requested therapist.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says that the information does not show that the enrollee failed or had inability to tolerate 
other available osteoporosis therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 pre-approve Prolia. Our reviewer says that Prolia is 
medically necessary at this time. Our physician reviewer found Prolia is indicated as a treatment to increase 
bone mass in women who are at high risk for fracture and receiving adjuvant aromatase inhibitor therapy for 
breast cancer. The review has determined that the documentation supports that Prolia is medically reasonable 
and necessary and supports that Prolia is safe and effective for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have been met. Therefore, we decided that the Plan has to pre-approve 
Prolia.  
 
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 unspecified preventive dental service (D1999) provided 
on July 10, 2020. 
 
You asked the Plan to pay for the unspecified preventive dental service. You say that you never received a 
denture from this provider. You say that the services you received should be covered. The Plan denied your 
request. The Plan says unspecified preventive dental service is not listed as a covered service. The Plan also 
says that any services not listed 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 unspecified preventive dental 
service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the unspecified preventive dental service (D1999) provided on July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99214) 
provided, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. You say that the services 
provided were medically necessary. 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 established patient office or other outpatient 
visit (99214) provided, by an out of network (OON) provider.