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

 
We decided that the Plan does not have to pay for the COVID-19 home test kits provided on April 3, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the COVID-19 home test kits. You say that a Plan representative told you that 
you would receive reimbursement. The Plan denied your request. The Plan says Medicare coverage 
information indicated coverage for home tests would be provided beginning on April 4, 2022. This purchase 
does not qualify for that benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that up to eight COVID-19 home test kits are covered 
beginning April 4, 2022.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the COVID-19 home test kits have not been met. Therefore, we decided that the Plan does not have 
to pay for the COVID-19 home test kits provided on April 3, 2022, 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 extractions (D7210) and parenteral drugs (D9612) for 
tooth #29 and #29 provided on April 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that these procedures would 
not be covered, and you paid the copayment you were told to pay. The Plan denied your request. The Plan says 
your benefit for the extractions has already been exhausted and the denial of payment for the parenteral drugs is 
correct, because it is not covered by the Plan. 
 
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 parenteral drugs are not among 
those covered under this benefit. The record also shows your benefit for the extractions was exhausted on date 
of service of April 29, 2022. Therefore, we decided that the Plan does not have to pay for the extractions 
(D7210) and parenteral drugs (D9612) for tooth #29 and #29 provided on April 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 23020, 23430) provided to 
the enrollee on March 16, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says these codes are inclusive to other codes. 
 
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 the denied codes is: 
 
CPT 23020: 
 Capsular contracture release (eg, Sever type procedure) 
 
CPT 23430: 
 
Tenodesis of long tendon of biceps 
 
We asked our coder 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. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 23020, the 
procedure report states that the capsule was released off the humeral head. However, this was part of the 
reverse total shoulder arthroplasty (as it was performed to access the humeral head to perform the replacement. 
This was also performed on the inferior capsule, in order to facilitate/perform the replacement of the glenoid. 
This was not a separate procedure, but part of the main procedure to allow for access of both parts of the 
shoulder to perform the reverse total shoulder. In terms of CPT 23430, the procedure report states a tenotomy 
was performed during the procedure to expose the glenoid to prepare it for the reverse total shoulder. After the 
final humeral trays were impacted, the biceps tenodesis was performed. This appears to also have been part of 
the primary procedure. Thus, this was not a separate and/or distinct procedure.  
 
We looked at this coder's review, the file, and Medicare rules. 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 surgical services (procedure code 23020, 23430) provided to the enrollee on March 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0426) 
provided on May 27, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for Ambulance services.  
 
 
  You have been asked to pay a $350 copayment for the ambulance transportation services. the ambulance 
transportation services falls within the Ambulance 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 ambulance transportation services (A0426) provided on May 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. 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. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns on tooth #11 and 13 (D6750). 
 
You asked the Plan to pre-approve retainer crowns. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says retainer crowns (D6750) are not covered by your dental 
benefits. 
 
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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
retainer crowns on tooth #11 and 13 (D6750).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no advantage in transferring the enrollee to the LTACH. The enrollee can 
remain at the current acute care hospital until such time no acute services are required. The enrollee can then be 
transferred/discharged to a lower level of care for any ongoing long-term care needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal root scaling and root planing, four or more teeth per 
quadrant (D4341). 
 
You asked the Plan to pre-approve periodontal root scaling and root planing. You say that the enrollee has 
pockets between his gums and teeth. The Plan denied your request. The Plan says that the records indicate the 
enrollee has pockets of space between their gums and her tooth. These records did not include the necessary 
documentation, such as evidence of bone loss. 
 
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. The Plan covers periodontal 
root scaling and root planing when the services are medically necessary and reasonable. 
 
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 periodontal root scaling and root 
planing. Our reviewer says that the service is medically necessary. Our physician reviewer found a review of 
the documentation indicates 5-6mm pathological periodontal pockets in the four quadrants with areas of bone 
loss. The documentation provided meets the criteria for coverage for periodontal scaling and root planing in 
four quadrants. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of periodontal root scaling and root planing have been met. Therefore, we decided 
that the Plan has to pre-approve periodontal root scaling and root planing, four or more teeth per quadrant 
(D4341).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were told the rendering provider was an in-
network provider and you received a referral from your primary care provider. The Plan denied your request. 
The Plan says the rendering provider is an OON provider and there is no valid referral for the date of service or 
an approved 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 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 an office visit provided on January 7, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional reimbursement for the x-ray exams of the cervical 
spine (72040 x 2) provided on October 25, 2021 and October 27, 2021. 
 
You asked the Plan to issue additional reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to issue additional reimbursement for the x-ray exams of the cervical spine  
(72040 x 2) provided on October 25, 2021 and October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incision and drainage of abscess (D7510) provided by a 
network provider on May 19, 2022. 
 
You asked the Plan to pay for the incision and drainage of abscess. You say that you were not aware you would 
have to pay out of pocket. The Plan denied your request. The Plan says the service was 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 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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
incision and drainage of abscess (D7510) provided by a network provider on May 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported crowns-porcelain fused to high noble 
alloys (D6066 x 2) and the surgical placement of a mini implant (D6013 x 2). 
 
You asked the Plan to pre-approve the items/services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these items/services are not a covered benefit under 
your contractual policy. 
 
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/services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
implant supported crowns-porcelain fused to high noble alloys (D6066 x 2) and the surgical placement of a 
mini implant (D6013 x 2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (84238, 82397, 83036, 83718) provided 
on December 12, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
  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 laboratory services (84238, 82397, 83036, 83718) 
provided on December 12, 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 a limited oral evaluation (D0140) provided by a participating 
provider on May 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan should pay for this. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 10, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on March 22, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
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 an office visit (99213) provided on March 22, 
2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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. Medicare rules also say that providers must report services correctly. Providers must report services 
with the appropriate procedure code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab 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. Additionally, we find that 
procedure code 99000 has a status indicator of B on the Physician Fee Schedule. This means that procedure 
code 99000 is not separately payable. Therefore, we decided that the Plan does not have to pay for lab services 
provided on October 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that your lab does not have access to patient 
demographics prior to the date of service nor do you have the patient's insurance information. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 The Plan must follow Medicare rules. Medicare rules say that, for 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 the lab 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 lab services provided on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on February 16, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that is it the facilities responsibility to obtain 
prior authorization and you would like reimbursement for the service provided. The Plan denied your request. 
The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved 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 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 the nursing facility care provided on February 16, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (93309) provided on January 4, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
  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 an office visit (93309) provided on January 4, 
2022 by an out-of-network (OON) provider.