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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee has transitioned out of the 
current care and needs to be in an SNF. You say that the enrollee has been in the current facility for a month 
and needs to continue rehab. You say that the intense rehab provided in the current facility is not necessary. 
You say that the enrollee's wife is unable to care for him in their home. The Plan denied your request. The Plan 
says the enrollee's needs appear custodial. The Plan says that the enrollee's needs can be met at a lower level of 
care. The Plan says that the enrollee does not require skilled services to be provided only on an inpatient basis 
in a SNF. 
 
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 SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and 
enteral nutrition and medications and insulin. The enrollee had stable vital signs. The enrollee received physical 
therapy, speech therapy, and occupational therapy in the acute hospital. The enrollee was at a moderate to 
maximal assist level or required a mechanical lift for transfers. The enrollee required varying assist with 
activities of daily living and had ongoing confusion. There are no identifiable skilled therapy service needs.  
 
 
 
There are identifiable skilled nursing service needs, but they are not required on a daily basis. The enrollee 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee has a new PEG tub and cannot 
eat anything by mouth. You say that the enrollee's medications are administered through the tube. The Plan 
denied your request. The Plan says there are no daily skilled nursing or therapy needs. The Plan says that the 
enrollee's rehab needs can be provided at a lower 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 pre-approve the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received enteral 
nutrition and medications. The enrollee had stable vital signs and had a medical decline on November 13, 2020, 
with lethargy, increasing oxygen requirements, a possible GI bleed and leukocytosis. The enrollee received 
physical therapy and occupational therapy in the acute hospital.  
 
 
The enrollee was at a minimal assist level with functional mobility. The enrollee required varying assist with 
activities of daily living. There are no identifiable skilled therapy service needs. There are identifiable skilled 
nursing service needs, but they are not required on a daily basis. The enrollee does not meet the 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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on June 11, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that NGS panels must be billed with procedure code 
81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 panel rendered on June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation and cone beam CT capture 
provided on June 18, 2020. 
 
You asked the Plan to pay for the cone beam CT capture. You say that the coverage package lists dental exams 
and x-rays covered at 50%. You say that you don't understand why your policy wouldn't pay 50% of the claim. 
The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation and cone beam CT capture provided on June 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided. 
 
You asked the Plan to pay for the laboratory 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 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 find that the laboratory services are not supported in the medical record. Specifically, the documentation 
submitted did not support that the laboratory testing was performed with blood sampling. The lab requisition 
does not show how the sample was collected. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe magnetic resonance imaging (MRI) of the abdomen rendered on September 18, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The file shows that the provider billed code 74181 with POS code 22 for outpatient;however, the enrollee was under inpatient status for the billed date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe magnetic resonance imaging (MRI) of the abdomen rendered on September 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis provided. 
 
You asked the Plan to pay for the prophylaxis. You say that you were told by a Plan representative that you 
could see this provider. The Plan denied your request. The Plan says the service was performed by an opt out 
provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the prophylaxis provided.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for speech therapy provided from October 
25, 2019, through November 22, 2019 and physical therapy provided from February 20, 2020, through March 
11, 2020. 
 
You asked the Plan to reduce the copayments for speech therapy and physical therapy. You say that the 
services should have been billed at $15 per visit because the services were not performed at the hospital. You 
say that your total share should have been $240 and $135. The Plan denied your request. The Plan says the 
copayments were applied 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 $40 
copayment for speech therapy and a $40 copayment for physical therapy provided by an in-network outpatient 
hospital.  

You have been asked to pay a total of $960 for speech therapy and physical therapy.  
 
Dates of Service Service Standard Copayment Number of Visits Member Liability 
October 25, 2019-
November 22, 2019 
Speech Therapy $40/visit 15 $600 
February 20, 2020-
March 11, 2020 
Physical Therapy $40/visit 9 $360 
TOTAL:    $960 
 
Speech therapy and physical therapy falls within the "Outpatient rehabilitation services" benefit category. The 
records show that the outpatient therapy was billed by the hospital. 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 reduce the 
copayments for speech therapy provided from October 25, 2019, through November 22, 2019 and physical 
therapy provided from February 20, 2020, through March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the allergy injection (95115) provided on July 13, 2020, by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the allergy injection. 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 allergy injection (95115) provided on July 13, 
2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sixty minutes of psychotherapy (90837) and psychiatric 
diagnostic evaluation (90791) provided on January 23, 2020 to April 22, 2020 by an out of network (OON) 
provider. 
 
You asked the Plan to pay for psychotherapy and psychotherapy diagnostic evaluation. You say that the 
services rendered were medically necessary. The Plan denied your request. The Plan says services must be 
rendered by an In-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 sixty minutes of psychotherapy (90837) and 
psychiatric diagnostic evaluation (90791) provided on January 23, 2020 to April 22, 2020 by an out of network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments charged for specialist physician services 
provided on May 1, 2020 and May 12, 2020. 
 
You asked the Plan to waive these copayments. You say that you do not believe these copayments are correct. 
The Plan denied your request. The Plan says according to pages 86-87 of your 2020 Evidence of Coverage, you 
are responsible for a $50.00 copayment for the services provided in a specialist physician office. The copay 
was correctly applied, the allowed amount on the claim was $7.90 and that whole amount has gone to 
copayment which is less than the $50.00 copayment. Your claim processed correctly; therefore, no changes can 
be made to your copayment. 
 
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 
copayment for each specialist office visit. 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 copayments charged 
for specialist physician services provided on May 1, 2020 and May 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis provided on June 29, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the prophylaxis. You say that you have been going to this dental practice for over 
30 years. You also say that you would like to continue visiting this dentist. The Plan denied your request. The 
Plan says the service was rendered by a non-participating 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 
prophylaxis provided on June 29, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the unspecified preventive service (D1999) 
provided on May 26, 2020. 
 
You asked the Plan to reimburse you for the dental service. You say that you paid for the PPE at the time of 
service. The Plan denied your request. The Plan says the unspecified preventive service is not listed as a 
covered service. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for 
the unspecified preventive service (D1999) provided on May 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided on May 23, 2020 through June 14, 2020.You asked the Plan to pay for SNF care provided on May 23, 2020 through June 14, 2020. You say that the services rendered were medically necessary.The Plan denied your request. The Plansays continued assistance with routine daily activities could be safely provided at the custodial level of care as it had been before.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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled therapy service needs and the beneficiary does not require skilled nursing or therapy services on a daily basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided on May 23, 2020 through June 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910), the initial periapical x-
ray (D0220), the additional periapical x-ray (D0230), and the topical application of fluoride varnish (D1206) 
provided on January 21, 2020. 
 
You asked the Plan to pay for the dental services. You say that you have been fraudulently billed for dental 
services that you did not receive. You say that you received 1 act of scaling and 1 act of fluoride in January. 
You also say that both of these services are allowed yearly. The Plan denied your request. The Plan says the 
services you received are not listed as covered services. 
 
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. Additionally, based on the records received from the provider, the 
services that were billed were provided. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910), the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), 
and the topical application of fluoride varnish (D1206) provided on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 4, 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 
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 May 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 25, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 
laboratory 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 laboratory services provided on November 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a behavioral health inpatient admission from July 12, 2020, 
through July 20, 2020. 
 
You asked the Plan to pay for the behavioral health inpatient admission. The Plan denied your request. The 
Plan says prior authorization was not obtained by the provider or facility. The provider should have verified the 
member's eligibility, health benefits and obtained authorization prior to the member?s visit before providing 
services to the member. 
 
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 a behavioral health inpatient admission from July 12, 2020, 
through July 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology examination of tissue (88305) provided on 
July 7, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the pathology examination of tissue. 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 pathology examination of tissue (88305) 
provided on July 7, 2020, by an out of network (OON) provider.