Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2750) provided on June 25, 2020. 
 
You asked the Plan to pay for the crown (D2750). You say that you want to know what is covered if a common 
crown procedure is not covered. 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 crown 
(D2750) provided on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 6, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for the out-of-network physician services. You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says you did not request prior authorization for the out-of-
network services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services 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 these services. Therefore, we decided that the 
Plan does not have to pay for the medical services provided on July 6, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient facility services provided. 
 
You asked the Plan to pay for the outpatient facility services. You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says this provider is ineligible for payment due to no Medicare ID on file. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a provider who 
is not enrolled in Medicare. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the outpatient facility services provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81201, 81209, 81242, and 
81403 provided. 
 
You asked the Plan to pay for the laboratory services. You say that you would like plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 81201, 81209, 81242, and 81403 are not supported in the medical record. Specifically, 
the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen 
was 
obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of 
service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was 
obtained in the 
home setting place of service 12. 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 coded 81201, 81209, 81242, and 81403 provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on July 16, 2020. 
 
You asked the Plan to waive the copayment for lab services. You say that you have never been charged in the 
past and disagree with the charges. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
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 $12 
copayment for lab tests.  
 
You have been asked to pay a $12 copayment for lab services. Lab services fall within the outpatient diagnostic 
tests and therapeutic services and supplies 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 lab services provided on July 16, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that medical records were requested. 
Please review the attached documentation and process for payment. The Plan denied your request. The Plan 
says that this is not medically necessary as the records do not show a medical reason for inpatient admission. 
 
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. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee with a history of Parkinson's disease presented to the ER for the 
evaluation of altered mental status. The evaluation including physical exam, laboratory studies and imaging 
revealed question of pneumoperitoneum. He was evaluated by General Surgery and underwent a diagnostic 
laparoscopy which revealed Pneumatosis cystitis intestinalis without bowel perforation. He was placed on the 
medical floor and treated with fluids and Miralax. He was given 1 dose of IV Vancomycin due to 1 positive 
blood culture. His condition stabilized and improved. He tolerated an oral diet and was considered stable for 
transfer back to the nursing facility. The review has determined that the record showed that at the 
time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital 
care (including earlier ED and/or observation care) would span two midnights. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided.  
 
 
 
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 pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the mandibular partial denture. The Plan denied your request. The Plan says 
this service is allowed one time every 60 months. The Plan also says that the enrollee received this service less 
than 60 months ago. 
 
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, mandibular dentures are limited to 
once per 60 months. The record shows that the enrollee received a mandibular partial denture (D5212) on May 
22, 2018, and the enrollee's mandibular denture benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve topical application of fluoride, excluding varnish 
(D1208) and periodontal maintenance (D4910). 
 
You asked the Plan to pre-approve the topical application of fluoride and periodontal maintenance. The Plan 
denied your request. The Plan says topical application of fluoride is not a covered benefit. The Plan also says 
that periodontal maintenance does not meet the benefit criteria. 
 
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, topical application of fluoride, 
excluding varnish is not among those covered under this benefit. The contract clearly states that periodontal 
maintenance (D4910) is not allowed within 90 days of scaling and root planing. The record shows that the 
enrollee received scalings and root planings on September 30, 2020, hence, the benefit criteria for a periodontal 
scaling and root planing has not been met. Therefore, we decided that the Plan does not have to pre-approve 
topical application of fluoride, excluding varnish (D1208) and periodontal maintenance (D4910).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 9, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the enrollee's 
plan requires utilization of network providers, and authorization for certain services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the lab 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 OON services. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on January 9, 2020 by an out of network (OON) 
provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance services provided to the enrollee on October 23, 2019.You asked the Plan to pay forthe services. You say that this is covered by Medicaid.The Plan denied your request. The Plan says this is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare Rules. Based on this information, we decided that Medicare rules for the services at issue have not been met. Specifically, the case file did not contain medical records for the billed services. Without the medical records, the billed services cannot be verified.  Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forambulance services provided to the enrollee on October 23, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunohistochemistry or immunocytochemistry services 
coded 88341 provided on January 17, 2020. 
 
You asked the Plan to pay for the immunohistochemistry or immunocytochemistry 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. 
 
In this case, the CPT Code Manual definition of code 88341 is immunohistochemistry or 
immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in 
addition to code for primary procedure). 
 
We find that CPT code 88341 is not supported in the medical record. Specifically, this code was billed without 
an appropriate primary code. Based on this information, we decided that Medicare rules for coverage of the 
immunohistochemistry or immunocytochemistry services have not been met. Therefore, we decided that the 
Plan does not have to pay for the immunohistochemistry or immunocytochemistry services coded 88341 
provided on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the specialist office visit and x-rays provided 
on August 14, 2020. 
 
You asked the Plan to waive the copays for the services provided. You say that you assumed all copays were 
waived during COVID, no matter the situation. The Plan denied your request. The Plan says the claim processed 
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).  
 
You have been asked to pay a $25 copay for x-rays, and a $40 copay for the office visit. The services fall 
within the outpatient diagnostic tests and physician services benefit categories. 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 copays for the specialist office visit and x-rays provided on August 14, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for food and excess lodging expenses. 
 
You asked the Plan to reimburse you for food and excess lodging expenses. You say that the Plan should 
reimburse you for food and personal supplies. The Plan denied your request. The Plan says you were 
reimbursed for covered travel and lodging expenses. 
 
The Plan must follow Medicare rules. Medicare rules say that enrollees are responsible for paying the full cost 
of services that aren't covered by the Plan either because they are not plan covered services or plan rules were 
not followed. 
 
We looked at the file and Medicare rules. Food and personal supplies are non-covered items. The Plan has 
reimbursed you for lodging and transportation costs. Therefore, we decided that the Plan does not have to 
reimburse you for food and excess lodging expenses.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for an arthrocentesis, aspiration, 
or injection (20650) performed on June 10, 2020. 
 
You asked the Plan to waive the deductible and copayment for an arthrocentesis, aspiration, or injection. You 
say that the charge should be resubmitted as a doctor's visit fee. The Plan denied your request. The Plan says 
the correct cost-sharing was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $300 deductible and 10% coinsurance for each Medicare-covered 
outpatient hospital facility visit.  
 
The item or service you asked the Plan to waive the deductible and copayment for falls within the "Outpatient 
surgery" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $300 deductible for each Medicare-covered outpatient hospital facility visit. This cost sharing is a 
contractual obligation that had not been met at the time an arthrocentesis, aspiration, or injection was received 
on June 10, 2020. 
 
You have also been asked to pay an additional $5, or 20% of the Plan-allowed amount of $50 after the 
deductible is met, for an arthrocentesis, aspiration, or injection. This means that the $305 you have been asked 
to pay is 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 deductible and copayment for an arthrocentesis, aspiration, or injection (20650) performed on June 10, 
2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fordiagnostic breast imaging (CPT 77061) provided to the enrollee on June 24, 2020.You asked the Plan to pay forthe imaging. You say that this should be paid for.The Plan denied your request. The Plan says Medicare uses another code for reporting/payment of these services.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 77061 is "Diagnostic digital breast tomosynthesis; unilateral."Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the imaging have not been met.Therefore, we decided that the Plan does not have to pay fordiagnostic breast imaging (CPT 77061) provided to the enrollee on June 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional speech therapy visits. 
 
You asked the Plan to pre-approve additional speech therapy visits. The Plan denied your request. The Plan 
says additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional speech therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the unique skills of a professional therapist are 
not required to safely and effectively provide ongoing treatment. 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional speech therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional speech therapy visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a robotic partial nephrectomy to be provided by the out-
of-network facility. 
 
You asked the Plan to pre-approve the robotic partial nephrectomy. The Plan denied your request. The Plan 
says the Plan does not cover services provided by out-of-network providers and facilities. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a robotic 
partial nephrectomy to be provided by the out-of-network facility.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 11 additional occupational therapy visits. 
 
You asked the Plan to pre-approve 11 additional occupational therapy visits. The Plan denied your request. The 
Plan says additional visits over the limit are not necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 11 additional occupational therapy 
visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that the unique skills of a professional 
therapist are not required to safely and effectively provide ongoing treatment. 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 11 additional occupational therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 11 additional occupational therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on  
by an out of network (OON) provider. 
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that the patient needs additional 
therapies. The Plan denied your request. The Plan says there are multiple in-network providers available able to 
treat the enrollee's condition. 
 
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 chiropractic manipulative treatment (98941) 
provided on  by an out of network (OON) provider.