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

 
We decided that the Plan does not have to pay for Telephone evaluation provided on December 17, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Telephone evaluation. You say that requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the provider is out-of-network and it was determined these 
services were not urgent or emergent. 
 
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 had network providers 
available who could have provided 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 Telephone evaluation provided on December 17, 
2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 26, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on July 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the patient's outlined therapy methods and goals are standard 
postoperative measures that are able to be met at a subacute rehabilitation facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for cervical spine 
surgery complicated by hematoma requiring operative management. The enrollees medical problems are 
stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full mouth debridement (D4355), comprehensive oral 
evaluation (D0150), and complete series of intraoral x-rays (D0210) provided on January 4, 2022. 
 
You asked the Plan to pay for the full mouth debridement, comprehensive oral evaluation, and complete series 
of intraoral x-rays. You say that the dentist you saw on July 22, 2021 told you they wanted to pull 3 teeth, 
which is why you went to another dentist on January 4, 2022. You also say that no one advised that you would 
have to pay anything, and you are living on a fixed income. The Plan denied your request. The Plan says the 
full mouth debridement is not a covered expense under your dental plan. The Plan also says that your 
comprehensive oral evaluation and complete series of intraoral x-rays benefits have been satisfied and the 
frequency limitations have been exceeded. 
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, full mouth debridement (D4355) not 
among those covered under this benefit. The contract says that comprehensive oral evaluation (D0150) is 
limited to 1 procedure code every 3 calendar years, and full mouth or panoramic x-rays share a frequency 
limitation of 1 procedure code every 5 calendar years. The record shows that you received a comprehensive 
oral evaluation (D0150) and panoramic x-ray (D0330) on July 22, 2021 and your comprehensive oral 
evaluation (D0150) and full mouth or panoramic x-rays benefits have been exhausted. Therefore, we decided 
that the Plan does not have to pay for the full mouth debridement (D4355), comprehensive oral evaluation 
(D0150), and complete series of intraoral x-rays (D0210) provided on January 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at this time the CardioMEMS system would not be considered medically appropriate 
and necessary in this enrollees clinical management. 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), 
first intraoral periapical x-ray (D0220), and additional intraoral periapical x-ray (D0230) provided on January 
24, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and intraoral periapical x-rays. You say 
that prior to this appointment you asked the receptionist if the dentist still accepted your insurance, and you 
were told yes. You also say that you do not have $144 to pay for these services, and feel like you were misled. 
The Plan denied your request. The Plan says services performed by an OON provider are not covered because 
your healthcare plan does not have OON benefits. The Plan also says that you did not contact the Plan prior to 
the date of service to verify benefits and provider eligibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation (D0120), prophylaxis (D1110), first intraoral periapical x-ray (D0220), and additional intraoral 
periapical x-ray (D0230) provided on January 24, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on January 12, 
2022. 
 
You asked the Plan to waive the deductible for the office visit. You say that the services should be covered as 
you disagree with the charges. 
 The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 $233 deductible which applies to Physician/Practitioner services, 
including doctor's office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner services, including doctor's office visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $233 deductible which applies to Physician/Practitioner 
services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at 
the time the office visit was received on January 12, 2022. Therefore, we decided that the Plan does not have to 
waive the deductible for an office visit provided on January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82310, 82728, 83540, 83550, 84100) provided 
October 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says these services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services furnished to individuals for 
the treatment of end-stage renal disease (ESRD) are included in the ESRD PPS as Part B services and are not 
paid separately as of January 1, 2011. 
 
 
 
 
 
 We looked at the file and Medicare rules. The lab services are included in payment for the dialysis services and 
cannot be paid separately. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (82310, 
82728, 83540, 83550, 84100) provided October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chiropractic services provided on January 
18, 2022. 
 
You asked the Plan to waive the copayment for the chiropractic services. You say that you have 6 visits per 
year and they should be fully covered. 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 an $18 
copayment for each chiropractic service from a tier 1 provider.  
 
You have been asked to pay an $18 copayment for the chiropractic services. The chiropractic services fall 
within the Chiropractic Services 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 chiropractic services provided on 
January 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 2, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on July 2, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug is needed to treat persistent 
anemia in chronic renal insufficiency. The Plan denied your request. The Plan says that there is not enough 
support for Aranesp to use for treatment of anemia due to acquired pure red cell aplasia. The Plan sasy that this 
is not supported by the FDA and/or nationally recognized compendia. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Aranesp. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found Aranesp is FDA approved for the treatment 
to anemia of chronic kidney disease. This enrollee has worsening renal function and is receiving treatment with 
cyclosporine. They are requiring frequent transfusions and a trial of Aransep to see if there is a component of 
anemia of chronic kidney disease that may decrease the need for transfusions. This requested drug is 
reasonable, medically necessary, safe and possibly effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have been met. Therefore, we decided that the Plan has to pre-approve 
Aranesp.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus testing (U0003, U0005) provided on August 
31, 2021. 
 
You asked the Plan to pay for the laboratory testing. You say that the services should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 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 coronavirus testing (U0003, U0005) provided on August 
31, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary. 
The Plan denied your request. The Plan says rules for SNF care have 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 in the Medicare rules section 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 based on the medical records provided there is 
no documentation that the patient requires skilled nursing services, i.e., the specialized skill, knowledge and 
judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary 
and reasonable treatment. Records do not document the need for intravenous medications, new tube feeding or 
ostomy care or daily complex wound care. While this patient does require skilled therapy services, these 
services are not required on a daily basis. Based on the medical records provided there is no documentation that 
the patient requires the services on an inpatient basis, only in a skilled nursing facility setting. Records do not 
document that services in the long-term care facility on a part time basis are not appropriate in this case. 
 
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 admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), and endodontic therapy 
(D3330) provided on October 30, 2021, and November 20, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, intraoral periapical x-rays, and 
endodontic therapy. You say that the Plan's website shows that this treating provider is in-network. You also 
say that you would like payment to be remitted immediately. The Plan denied your request. The Plan says 
services performed by an OON provider are not covered because your healthcare plan does not have OON 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), additional 
intraoral periapical x-ray (D0230), and endodontic therapy (D3330) provided on October 30, 2021, and 
November 20, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized deliveries of antimicrobial agents (D4381) and 
gingival irrigations (D4921) provided on October 7, 2021. 
 
You asked the Plan to pay for the localized deliveries of antimicrobial agents and gingival irrigations. You say 
that you would like these claims to be reconsidered for coverage. The Plan denied your request. The Plan says 
these services are not covered expenses 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 
localized deliveries of antimicrobial agents (D4381) and gingival irrigations (D4921) provided on October 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the folding walker purchased on November 23, 2021. 
 
You asked the Plan to pay for these services. You say that the network providers were not bale to get the 
Rollator walkers. The Plan denied your request. The Plan says the provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows that the provider is not Medicare-certified. Therefore, 
we decided that the Plan does not have to pay for the folding walker purchased on November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator (AED) 
device provided from August 27, 2021, to October 27, 2021. 
 
You asked the Plan to waive the coinsurance for the AED device. You say that you were not aware of any costs 
at the time. You say that you would not be allowed to be discharged without it. The Plan denied your request. 
The Plan says the correct coinsurance 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 each durable medical equipment (DME) item, including AED devices. 
 
 Item Allowed Amount 20% Coinsurance 
AED Device  August 27, 2021 $2,800 $560 
AED Device  September 27, 2021 $2,800 $560 
AED Device  October 27, 2021 $2,800 $560 
Total:  $1,680 
 
You have been asked to pay $1,680, which is 20% of the allowed amount for the AED device. The AED device 
falls within the Durable Medical Equipment (DME) and Related 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 an automatic external defibrillator (AED) device provided from 
August 27, 2021, to October 27, 2021.