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

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on November 
25, 2019 by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that it is your understanding that if 
a provider is called to see an enrollee during their nursing home stay, that your services would be covered by 
Medicare. You also say that you understand if any authorization is needed, the nursing home would be 
responsible for obtaining authorization. The Plan denied your request. The Plan says the provider did not 
contact the enrollee's plan for authorization of the services. The Plan also says that the Plan and Medicare rules 
require the enrollee to obtain covered services from Plan providers, except for emergency care and out-of-area 
urgent care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. 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 subsequent nursing facility care provided on 
November 25, 2019 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on October 10, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. 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 for the drug testing services provided on October 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis provided on May 5, 2020. 
 
You asked the Plan to pay for the prophylaxis. You say that you were told by your broker that you were able to 
receive cleanings twice a year. You also say that you were not aware it was every six months. The Plan denied 
your request. The Plan says this service was denied because it exceeds the frequency limitation in your benefit 
plan. The Plan also says they confirmed with your provider that you were advised you needed to come in four 
months from December, and the upcoming visit would not be covered by your insurance because your 
insurance only covers prophylaxis every six months. 
 
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, prophylaxis is limited to 1 visit every 
six months. The record shows that you received a prophylaxis on December 17, 2019 and your prophylaxis 
benefit was then exhausted for the 6 month time period. Therefore, we decided that the Plan does not have to 
pay for the prophylaxis provided on May 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance services on December 25, 2019. 
 
You asked the Plan to pay for non-emergent ambulance services. You say that with the pain you were 
experiencing that your car was not adequate to transport you to the hospital and you had no other family that 
could assist in your transport. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergent ambulance services. Our 
physician reviewer found the documentation does not support that other means of transport (such as stretcher 
van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this patient on 
December 25, 2019. The patient had chronic back pain. It would have been reasonable to transport by an 
alternate means. The documentation does not support that the patient needed the expertise, services and 
lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on 
December 25, 2019. The documentation does not support that the ambulance transport on December 15, 2019 
was medically reasonable and necessary for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergent ambulance services have not been met. Therefore, we decided 
that the Plan does not have to pay for non-emergent ambulance services on December 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Superion interspinous and/or interlaminar device. 
 
You asked the Plan to pre-approve Superion interspinous and/or interlaminar device. 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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Superion interspinous and/or 
interlaminar device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of lumbar 
radiculopathy and lumbar spinal stenosis. The requested device remains experimental. More research is needed 
to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested 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 Superion interspinous and/or interlaminar device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Superion interspinous and/or interlaminar device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on May 13, 
2020. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you do not understand why the Plan 
will pay for a regular cleaning, but will not pay for a periodontal maintenance cleaning. The Plan denied your 
request. The Plan says this service is not covered. The Plan also says that they received a treatment plan from 
your provider, signed by you, showing the charge for the periodontal maintenance was not covered, and you 
would be fully responsible for the charge for this 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, 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 
periodontal maintenance (D4910) provided on May 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable x-ray services (71046) February 9, 2020. 
 
You asked the Plan to pay for the portable x-ray services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were provided out-of-network and prior authorization 
was not given. 
 
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 portable x-ray services (71046) February 9, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair of a broken complete mandibular denture base 
(D5511), reline complete mandibular denture (D5751), and reline complete maxillary denture (D5750) 
provided on February 27, 2020 and March 9, 2020. 
 
You asked the Plan to pay for the repair of a broken complete mandibular denture base and relines of the 
complete mandibular and maxillary dentures. You say that the 2020 enrollment guide states that dentures may 
be covered. The Plan denied your request. The Plan says these services are not covered benefits under your 
dental 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 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 repair 
of a broken complete mandibular denture base (D5511), reline complete mandibular denture (D5751), and 
reline complete maxillary denture (D5750) provided on February 27, 2020 and March 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional physical therapy visits. 
 
You asked the Plan to pre-approve 2 additional physical therapy visits. You say that the injury affected your 
ability to be able to walk. You say that the exercise program significantly reduced the pain level. The Plan 
denied your request. The Plan says further physical therapy is not reasonable or 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 2 additional physical 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 you have had prior therapy and was given home 
exercises. Our reviewer says 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 2 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 2 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis, comprehensive oral evaluation and the 
intraoral complete series x-ray provided on March 4, 2020. 
 
You asked the Plan to pay for the prophylaxis, comprehensive oral evaluation and the intraoral complete series 
x-ray. You say that the office confirmed they were in-network. The Plan denied your request. The Plan says 
out-of-network dental 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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
prophylaxis, comprehensive oral evaluation and the intraoral complete series x-ray provided on March 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewings, and 
prophylaxis provided on February 20, 2020 by an OON provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, bitewings, and prophylaxis. You say that you 
went to a new dentist and called the Plan with the codes of future services the dentist wanted to provide. You 
also say that the Plan gave you the percentages of coverage. The Plan denied your request. The Plan says this 
provider had opted out of Medicare. 
 
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 comprehensive oral evaluation, bitewings, and prophylaxis provided on February 20, 2020 by an OON 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance provided on May 12, 2020. 
 
You asked the Plan to pay for periodontal maintenance. You say that the disallowed amount should not have 
been billed to you. The Plan denied your request. The Plan says a prophylaxis may be rendered up to one visit 
every six months. 
 
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 
periodontal maintenance provided on May 12, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 23, 2020 and 
January 24, 2020. 
 
You asked the Plan to pay for the medical services. You say that the claim has not been paid in full or under the 
terms of the contract for the services provided to this enrollee. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the enrollee's terminal condition. 
 
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 medical services provided on January 23, 2020 and 
January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on May 5, 2020. 
 
You asked the Plan to pay for the domiciliary or rest home visit. 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 
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 domiciliary or rest home visit provided on May 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the spinal injections provided on February 
18, 2020. 
 
You asked the Plan to waive the coinsurance for the spinal injections. You say that you were not aware that the 
facility was out-of-network. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing 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 40% 
coinsurance for out-of-network Medicare-covered surgery or other services provider to you at an ambulatory 
surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay $185.10 which is 40% of the allowed amount for the spinal injections. The total 
allowed amount is $462.73. ($462.73 x 40% = $185.10). The spinal injections fall within the ?Outpatient 
Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers? benefit category. The record shows the facility is out-of-network. 
 
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 coinsurance for the spinal injections provided 
on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the wound care provided on October 14, 
2019 and October 28, 2019. 
 
You asked the Plan to waive the copayments for the wound care. You say that you were instructed to go to this 
facility and these charges should not be billed to you. You say you cannot afford this copayment. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing 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 $50 
copayment for each visit for Medicare-covered outpatient hospital services.  
 
You have been asked to pay a $50 copayment for the wound care on each date of service. The wound care falls 
within the ?Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers? benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the wound care 
provided on October 14, 2019 and October 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for diabetic supplies (A4231, A4232) 
provided April 30, 2020. 
 
You asked the Plan to waive the coinsurance for the diabetic supplies. You say that the coinsurance should be 
waived. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Durable Medical Equipment and Supplies.  
 
You have been asked to pay a 20% coinsurance for the diabetic supplies. The diabetic supplies fall within the 
Durable Medical Equipment 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 coinsurance 
for diabetic supplies (A4231, A4232) provided April 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that the enrollee needs to 
continue physical therapy for weakness, falls and inability to ambulate. The Plan denied your request. The Plan 
says additional therapy services are not reasonable or 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 10 additional physical 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 the enrollee has had extensive therapy. 
Our reviewer says that their current level of function does not require ongoing skilled therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care, per day, for the evaluation and 
management of a patient (99232) provided March 1, 2020. 
 
You asked the Plan to pay for the subsequent hospital care. You say that your physician provided medically 
necessary services to the enrollee in good faith. In consideration for the services rendered, your doctor is 
seeking reimbursement. The Plan denied your request. The Plan says this is a duplicate of a charge considered 
on a previous claim. 
 
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 billing of code 99238 was submitted inappropriately due to the bundled relationship of services 
within the specialty group. This service has already been paid to another physician. This code can only be 
billed once per day. Based on Medicare billing guidelines, this claim cannot be paid as billed. Therefore, we 
decided that the Plan does not have to pay for subsequent hospital care, per day, for the evaluation and 
management of a patient (99232) provided March 1, 2020.