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

 
We decided that the Plan does not have to pay for the services provided on November 25, 2019. 
 
You asked the Plan to pay for the services. You say that you are requesting reimbursement of services 
rendered. You state that you did not have other insurance during the time of services. The Plan denied your 
request. The Plan says you had other insurance during the date of service. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan state you had 
other insurance at the time of service. The Plan reached out to the coordination of benefits team who verified 
that you had other insurance that did not terminate until November 30, 2019. The claim needs to be filed with 
the other insurance company first and the explanation of benefits would need to be sent to this Plan. As the 
secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the 
claim for these services. Therefore, we decided that the Plan does not have to pay for the services provided on 
November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ankle foot orthosis (L1971) and shoulder elbow wrist hand 
orthosis (L3960) provided on December 23, 2019. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the orthoses have not been met. Documentation submitted did not 
include a valid physician order and did not indicate the provider discussed the need for the billed supply code; 
therefore, the billed supply code cannot be verified. Of note, the Delivery Ticket submitted did not include the 
carrier's tracking number, nor did the Proof of Delivery include an order number or details to corroborate the 
Delivery Ticket submitted. Therefore, we decided that the Plan does not have to pay for ankle foot orthosis 
(L1971) and shoulder elbow wrist hand orthosis (L3960) provided on December 23, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been 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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee is now mostly supervised for all 
care. The enrollee has no complex wound care needs, or IV medication requirements. There are no nursing or 
therapy needs that are skilled, and warranting a SNF as opposed to a lesser level of care (including home health 
care services).  The enrollees vital signs are stable, labs are stabilizing, and SNF is not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on 
December 11, 2019. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that in 2019 you were 
eligible for 2 cleanings, so you should not have to pay for this second preventive cleaning. The Plan denied 
your request. The Plan says this provider was no longer in-network on this date of service. The Plan also says 
that this provider can bill you the $56 difference. 
 
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 may pay more for services 
received by an OON provider. Therefore, we decided that the Plan does not have to pay for the periodic oral 
evaluation and prophylaxis provided on December 11, 2019.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided on December 3, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid by the Plan. The Plan denied 
your request. The Plan says due to the hospice election at the time of service, this claim must be submitted to 
Original Medicare first. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. The Medicare hospice benefit was active for the dates 
of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for emergency room 
services provided on December 3, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repetitive transcranial magnetic stimulation (rTMS) 
(90869, 90867, 90868). 
 
You asked the Plan to pre-approve rTMS. You say that the enrollee has tried many medications and is unable 
to function. The Plan denied your request. The Plan says the records are not sufficient to show this is necessary. 
 
The Plan follows Medicare rules. Medicare rules say that rTMS is considered medically necessary only when 
all of the above listed criteria are met.  
 
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 rTMS. Our reviewer says that the 
requested rTMS treatments are not shown to be medically necessary at this time. Our physician reviewer found 
based on the information provided, this patient does not meet the clinical criteria for the use of rTMS therapy, 
as this patient?s medication use is not clearly documented. It is unclear if this patient?s medication use has been 
in the present episode of depression. There is no clear documentation of this patient?s provider utilizing 
augmentation therapy. There is no documentation of this patient undergoing and failing psychotherapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of rTMS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve repetitive transcranial magnetic stimulation (rTMS) (90869, 90867, 90868).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay you had from 
February 28, 2020 through March 2, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not happy 
with the service you received at the hospital.  You said that the room you were in did not have space for visitors 
and just had curtains separating it from others. You also stated that you could have just stayed at home to wait 
for a physician consult instead of staying in the hospital. The Plan denied your request. The Plan says you were 
charged this cost sharing 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 $360 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $360 copayment per day for the inpatient hospital stay. 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, and you are responsible for it regardless of why 
you were in the hospital. Therefore, we decided that the Plan does not have to waive the copayment for the 
inpatient hospital stay you had from February 28, 2020 through March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 23, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that the medically necessary services were 
provided to the member in good faith. The Plan denied your request. The Plan says this provider does not work 
with the member's plan and the member self-directed for services through their non-participating nursing 
facility. 
 
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 medical services provided on January 23, 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 debridement service (11042) rendered by the out of 
network (OON) provider on August 29, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the debridement service (11042) rendered by the out of network (OON) provider on  
August 29, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to the enrollee from January 9, 2020 
through April 9, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. This provider is a licensed 
professional counselor. As stated in the Medicare Program Integrity Manual, Chapter 15, Licensed Professional 
Counselors are not eligible to participate in the Medicare Program. Therefore, we decided that the Plan does 
not have to pay for the services provided to the enrollee from January 9, 2020 through April 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 12, 2020. 
 
You asked the Plan to pay for the laboratory 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 
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 May 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on October 3, 2019. 
 
You asked the Plan to pay for the radiology services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says Original Medicare is responsible for this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the radiology services provided on October 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to the enrollee on June 25, 2018. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says they are not the primary payer for this member on this date of services. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has needs the 
Explanations of Benefits from the primary insurance before the Plan can consider this claim for payment. As 
the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied 
the claim for these services. Therefore, we decided that the Plan does not have to pay for the services provided 
to the enrollee on June 25, 2018.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on January 7, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on January 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up, including any pins when required, (D2950). You asked the Plan to pre-approve the dental service. The Plan denied your request. The Plan says core build up 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 Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up, including any pins when required, (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the glass crown (D2740) and the core-build up (D2950) provided by an out of network provider on August 7, 2019. You asked the Plan to pay for these services. You say that the dental services provided were medically necessary. The Plan denied your request. The Plan says the dental services provided are not covered as they were rendered by a provider who is not part of the supplemental dental network. 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. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Specifically, the dental services were provided by an out of network provider who is not contracted with the plan's supplemental dental network. Therefore, we decided that the Plan does not have to pay for the glass crown (D2740) and the core-build up (D2950) provided by the out of network provider on August 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gum medication (D4381) for teeth # 3, 14, 19, and 30, and the mouth guard for teeth grinding (D9944). You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says the gum medication and mouth guard 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 dental item and services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gum medication (D4381) for teeth # 3, 14, 19, and 30, and the mouth guard for teeth grinding (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950 x 2), prefabricated post and core in addition to a crown (D2954), and a crown (D2740). You asked the Plan to pre-approve the core build up and prefabricated post and core in addition to a crown. You say that the Plan denied your request. The Plan says core build up is not a covered service. The Plan also says that prefabricated post and core in addition to a crown is not 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 Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, core build up and prefabricated post and core in addition to a crown are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950 x 2), prefabricated post and core in addition to a crown (D2954), and a crown (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extractions (code D7140) of tooth #'s 29 and 31. You asked the Plan to pre-approve the extractions of tooth #'s 29 and 31. The Plan denied your request. The Plan says this service is not a covered benefit under the enrollee's current 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 extraction services represented by code D7140 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve extractions (code D7140) of tooth #'s 29 and 31.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revascularization services provided on December 10, 
2019. 
 
You asked the Plan to pay for the services provided. You say that CPT code 37222 represents an angioplasty of 
additional vessel. Angioplasty was performed on the external and common iliac arteries. 
 The Plan denied your request. The Plan says the code is not supported by the medical record. 
 
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 37222 is Revascularization, endovascular, open or 
percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately 
in addition to code for primary procedure). We asked our coding 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 the 
services provided. Our reviewer says that that the documentation submitted does not meet coverage criteria. 
The operative report did not include documentation of the procedure code 37222-RT. Therefore, this code 
cannot be verified. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the revascularization services provided on December 10, 2019.