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

 
We decided that the Plan does not have to pay for Special stain including interpretation and report; Group I for 
microorganisms. 
 
You asked the Plan to pay for Special stain, 4 units (88312). You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says the submitted medical records do not support the units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 88312 is not supported in the medical record. Specifically, the medical records do not 
indicate that Special stain including interpretation and report; Group I for microorganisms was performed. 
Based on this information, we decided that Medicare rules for coverage of Special stain, 4 units (88312) have 
not been met. Therefore, we decided that the Plan does not have to pay for Special stain including 
interpretation and report; Group I for microorganisms.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound services provided on March 21, 2020. 
 
You asked the Plan to pay for the ultrasound 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 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. 
 
In this case, the CPT Code Manual definition of code 76856 is ultrasound, pelvic (nonobstetric), real time with 
image documentation; complete. 
 
We find that CPT code 76856 is not supported in the medical record. Specifically, this service was already 
billed and paid on April 17, 2020. This service is an exact duplicate to the services previously processed. Based 
on this information, we decided that Medicare rules for coverage of the ultrasound services have not been met. 
Therefore, we decided that the Plan does not have to pay for the ultrasound services provided on March 21, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating 
provider on My 11, 2020 to May 22, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you have to get an ultrasound once 
to twice a year. You say that you do not think it is fair you have to pay this additional copayment. The Plan 
denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for outpatient diagnostic tests/in-network/other outpatient diagnostic tests.  
 
You have been asked to pay a $15 copayment for each ultrasound. The total amount you are being asked to pay 
is $30 ($15 x 2 ultrasounds = $30). The correct copayments have been applied to the services provided. An 
ultrasound falls within the outpatient diagnostic tests/in-network/other outpatient diagnostic tests 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 ultrasound provided by a participating 
provider on My 11, 2020 to May 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a seat lift mechanism (E0627) provided on November 21, 
2019. 
 
You asked the Plan to pay for the seat lift mechanism. You say that you would like reconsideration because this 
equipment is medically necessary/ The Plan denied your request. The Plan says this service was billed with an 
inappropriate place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code E0627 
 is not supported in the record. Specifically, the record shows that this equipment was billed with a place of 
service code 99, indicating, "other." This does not indicate that this equipment is for primary use in your home. 
Based on this information, we decided that Medicare rules for coverage of the seat lift mechanism have not 
been met. Therefore, we decided that the Plan does not have to pay for a seat lift mechanism (E0627) provided 
on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services (97811) provided January 28, 2020 
to February 25, 2020. 
 
You asked the Plan to pay for the acupuncture services. You say that your doctor submitted a request for this 
treatment in January and it was approved. You called the plan to confirm the approval. Now you're being told it 
is not approved. The Plan denied your request. The Plan says this service is not covered under the plan benefits. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the out of network acupuncture provided did not have 
a valid referral is and not covered by your Plan contract. Therefore, we decided that the Plan does not have to 
pay for the acupuncture services (97811) provided January 28, 2020 to February 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on January 2, 2020. 
 
You asked the Plan to pay for the drug testing. You say that this testing was necessary and should be covered. 
The Plan denied your request. The Plan says there is no evidence that the enrollee is under the care of the 
ordering provider. 
 
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 definitive drug 
testing provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network 
(OON) provider on February 13, 2020. 
 
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 office visit (99214) rendered by the out of network (OON) provider on February 13, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the Pembrolizumab injections (J9271) provided on 
January 22, 2020 and February 11, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you have already reached your 
maximum out of pocket amount for medical services this year. The Plan denied your request. The Plan says 
that the coinsurance has been applied correctly to the services provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request.  Therefore, we decided that the Plan has to waive the coinsurance for the 
Pembrolizumab injections (J9271) provided on January 22, 2020 and February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on May 1, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to you by an out-of-network provider on May 
1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown re-cementing rendered on January 21, 2020. 
 
You asked the Plan to pay for these services. You say that you would like payment on the claim. The Plan 
denied your request. The Plan says further reimbursement 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. The Plan covers up to $200 for 
covered comprehensive dental benefits.  
 
We looked at the file and the Plan's rules. The file shows that the Plan reimbursed the full $200 allowance for 
these services. Further reimbursement is not covered by Medicare or the Plan. Therefore, we decided that the 
Plan does not have to pay for the crown re-cementing rendered on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 6, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the nursing facility services. You say that you would like reconsideration 
because the member is not responsible to ensure procedures rendered in the skilled nursing facility are covered 
and not all of the services billed were provided. The Plan denied your request. The Plan says there was no prior 
authorization for the non- contracted provider to provide any 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 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 February 6, 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 physician's services provided from September 12, 2019 to 
October 10, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the 
enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis 
while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, 
which requires prior authorization from the plan.  
 
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 from September 12, 2019 to 
October 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating 
provider on March 4, 2020. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you have never had to pay for an x-ray 
before. You say that you paid your copayment with the doctor and then you were told to get an x-ray. The Plan 
denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for outpatient diagnostic tests/in-network/x-rays.  
 
You have been asked to pay a $50 copayment for an x-ray. The correct copayment has been applied to the 
service that was provided. An x-ray falls within the outpatient diagnostic tests/in-network/x-rays 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 x-ray provided by a participating provider 
on March 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper and lower dentures (D5110, D5120).
You asked the Plan to pre-approve upper and lower dentures. You say that you need these covered because
your dentures broke. The Plan denied your request. The Plan says dentures are only covered once every five
years.
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, this benefit only covers dentures once
every five years. The record shows that the Plan previously covered dentures for you in March 2018.
Therefore, we decided that the Plan does not have to pre-approve upper and lower dentures (D5110, D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan has to pre-approve inpatient psychiatric hospital services after August 4, 2020. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer 
found the enrollee was admitted to the acute inpatient psychiatric hospitalization on July 15, 2020 with 
Unspecified Psychosis Not Due To a Substance or Known Physiologic Condition and Unspecified Intellectual 
Disabilities. The enrollee was compliant with treatment while not showing any acute threats to safety; the 
enrollee was unable to care for herself. It did appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question 
as the enrollee did not have dangerousness to self or others but was compliant with treatment. It did appear that 
active treatment was taking place beyond the date in question. It did appear that the services were reasonably 
expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. The 
enrollee was not showing any auditory hallucinations, the enrollee was showing visual hallucinations and was 
unable to care for herself. Therefore, the enrollee did meet criteria for the requested inpatient psychiatric 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve inpatient psychiatric hospital services after August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D9230, D7311, D9630) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is not medically necessary. The Plan denied 
your request. The Plan says this 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 pre-approve 
dental services (D9230, D7311, D9630) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99212) to be rendered by the out of 
network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested service. 
 
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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office 
visit (99212) to be rendered by the out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two additional extractions. 
 
You asked the Plan to pre-approve two additional extractions. You say that only one simple extraction or 
surgical removal of an erupted tooth is covered per year. The Plan denied your request. The Plan says a simple 
extraction or surgical removal of erupted tooth is covered once per year. 
 
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 Plan also has a maximum benefit 
of one extraction per year. The Plan pre-approved one extraction on July 8, 2020, which exhausted your 
benefit. Therefore, we decided that the Plan does not have to pre-approve two additional extractions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cone beam CT capture, guided tissue regeneration 
and bone replacement graft. 
 
You asked the Plan to pre-approve the cone beam CT capture, guided tissue regeneration, extraction and bone 
replacement graft. You say that your health is very affected and you feel bad psychologically. You say that you 
need this to be resolved. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 pre-approve the 
cone beam CT capture, guided tissue regeneration and bone replacement graft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) for the enrollee. 
 
You asked the Plan to pre-approve a CGM. You say that this is medically necessary. The Plan denied your 
request. The Plan says that your medical records do not show that you use insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above 
criteria have been met. 
 
We looked at the file and Medicare rules. The file indicates the enrollee is not treated by insulin injections three 
or more times a day or testing his blood glucose four or more times a day. Based on this information, we 
decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor (CGM) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing services. 
 
You asked the Plan to pre-approve genetic testing services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The genetic testing at issue in this appeal is being requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve 
genetic testing services.