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

 
We decided that the Plan does not have to pay for Subsequent nursing facility care provided on November 24, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Subsequent nursing facility care. You say that you would like to appeal the 
denial of the claim. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
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 Subsequent nursing facility care provided on 
November 24, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided on October 6, 
2021, to December 20, 2021. 
 
You asked the Plan to pay for the services provided. You say that you have made significant progress with your 
counselor. The Plan denied your request. The Plan says the provider is not eligible to bill Medicare for mental 
health services. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider shall receive payment for services 
furnished to a Medicare beneficiary unless the provider is enrolled in the Medicare program. The file shows that you received outpatient mental health services from a licensed professional counselor. We 
looked at the file and the rules. A professional counselor is not eligible to participate in Medicare. 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 outpatient mental health services provided on October 6, 
2021, to December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), 
complete series of intraoral x-rays (D0210), two surgical extractions (D7210 x2), and two bone replacement 
grafts for ridge preservation (D7953 x2) provided on December 22, 2021 by a specialist. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, complete series of intraoral x-rays, 
surgical extractions, and bone replacement grafts. You say that this treating provider is the only in-network 
provider within 15 miles of your home. You also say that you would like to be reimbursed for the expenses you 
incurred. The Plan denied your request. The Plan says there is no coverage for services provided by a specialist 
under the Plan's network. 
 
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 by a specialist. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140), complete series of intraoral x-rays (D0210), two surgical 
extractions (D7210 x2), and two bone replacement grafts for ridge preservation (D7953 x2) provided on 
December 22, 2021 by a specialist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of an implant body (D6010) 
 
You asked the Plan to pre-approve a surgical placement of an implant body. You say that you do not 
understand why the crown and the extension were approved but not the placement of the metal post. You also 
say it is painful and hard to eat in the area of that tooth and you would like the Plan to approve this procedure. 
You cannot wait another year of living in pain. The Plan denied your request. The Plan says you have 
exhausted the maximum benefit for the requested service. 
 
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 two surgical 
placements of an implant body every calendar year and 1 per tooth every five calendar years.  
 
 
 
 
 We looked at the file and Medicare rules. The records show that you received two surgical placements of an 
implant body on April 18, 2022, therefore, you have exhausted your maximum benefit for this service Based on 
this information, we decided that the Plan's rules for coverage of a surgical placement of an implant body have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a surgical placement of an 
implant body (D6010)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgical services provided on 
December 16, 2021. 
 
You asked the Plan to waive the copayment for outpatient surgical services. You say that you are on a very 
limited fixed income from social security and this bill is more than half of your rent, which would leave you 
without absolutely anything to live on. The Plan denied your request. The Plan says you were 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 $325 
copayment for each Medicare-covered outpatient hospital facility visit.  
 
You have been asked to pay a $325 copayment for outpatient surgical services. Outpatient surgical services fall 
within the outpatient surgery 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 outpatient 
surgical services provided on December 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for MRI provided on July 9, 2021. 
 
You asked the Plan to waive the copayment for MRI. You say that the copayment should be for the procedure 
performed in a specialist office. The Plan denied your request. The Plan says copayment is correct. 
 
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 $100 
copayment for advanced imaging services at an in-network freestanding radiological facility.  
 
You have been asked to pay $100 copayment for the MRI. The MRI falls within the Outpatient diagnostic 
tests and therapeutic services 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 copayment 
for MRI provided on July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on February 2, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the outpatient services. You say that you have sent in the medical records for the 
date of service and would like the claim reconsidered. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no 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 outpatient services provided on February 2, 2022, 
by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital ambulatory surgery center services provided on 
January 28, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for hospital ambulatory surgery center services. You say that you would like to 
request 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 hospital ambulatory surgery center services 
provided on January 28, 2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 21, 
2021. 
 
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 an appropriate modifier was not reported in this case. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on November 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to 
the enrollee on October 21, 2021. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says Medicare Part B covers cardiovascular disease screening tests when ordered by the 
physician who is treating the beneficiary for the purpose of early detection of cardiovascular disease in 
individuals without apparent signs or symptoms of cardiovascular disease. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the patient is already at a high risk of a cardiovascular event based on their history and it was not clear from the documentation how genetic testing would lead to a significant change in recommended treatment for 
their conditions or how it would lead to an overall improved outcome for this patient. Therefore, without 
sufficient support made for this request, the cardiac risk assessment genetic screening testing will be considered 
not medically necessary based on the provided records.  
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiac risk assessment genetic screening testing provided to the enrollee on October 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foot, insert, removable, molded to patient model 
(L3000). 
 
You asked the Plan to pre-approve foot inserts. You say that the shoe inserts are medically necessary for the 
enrollee. The Plan denied your request. The Plan says orthopedic shoe inserts are covered if they are an integral 
part of a leg brace and medically necessary for the proper function of the brace. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are covered for patients who wear a 
leg brace and medically necessary for the proper function of the brace. The Plan follows these same rules.   
 
Records show that the enrollee does not wear a leg brace. Although orthotics may be appropriate for the 
enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, 
we decided that the Plan does not have to pre-approve a foot, insert, removable, molded to patient model 
(L3000).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 4, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the rendering and referring providers are both OON 
providers and there was no approved authorization. Also, the service rendered was 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 the laboratory services provided on January 4, 
2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan of head or brain (70450) provided on January 6, 
2022. 
  You asked the Plan to pay for the CT scan of head or brain (70450). You say that the enrollee had multiple 
exams on this date of service. You say that the attached reports support the level of service, and the claim 
should be reconsidered for processing. The Plan denied your request. The Plan says an appropriate modifier 
was not billed with this code edit. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the CT scan of head or brain (70450) provided on January 6, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to 
the enrollee on October 2, 2021. 
 
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare Part B covers cardiovascular disease screening tests when ordered by the 
physician who is treating the beneficiary for the purpose of early detection of cardiovascular disease in 
individuals without apparent signs or symptoms of cardiovascular disease. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided documentation did not clearly describe how the results of genetic testing would reasonably lead to a significant change in treatment plan and overall outcome compared to standard treatment 
recommendations for this patient's conditions. Therefore, without sufficient support made for this request, 
the cardiac risk assessment genetic screening testing will be considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiac risk assessment genetic screening testing provided to the enrollee on October 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the copayment for physical therapy services provided 
from May 19, 2021, to 08/05/2021. 
 
You asked the Plan to reimburse the copayment for the physical therapy 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 $35 
copayment for Outpatient rehabilitation services.  
 
 
  You have been asked to pay a $35 copayment for 10 physical therapy visits ($35 x 10 = $350). These services 
are ineligible to be reimbursed as they do not fall under the health and wellness education programs category. 
Physical therapy services fall within the Outpatient rehabilitation 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 reimburse the copayment for physical therapy services provided from May 19, 2021, to 
08/05/2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removable denture services (D6111). 
 
You asked the Plan to pre-approve the removable denture services. You say that this is medically necessary. 
The Plan denied your request. The Plan says this dental care is not covered under your supplemental dental 
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 pre-approve the 
removable denture services (D6111).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on November 26, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the rendering provider is a non-participating provider, and the referring 
provider involved in these services is a non-participating provider with 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 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 drug testing provided on November 26, 2021, by 
an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychiatric transcranial magnetic stimulation (TMS). 
 
You asked the Plan to pre-approve psychiatric TMS. You say that the clinical documentation provided supports 
the need for TMS. The Plan denied your request. The Plan says the requested service is not covered by 
Medicare for the enrollee's condition. 
 
The Plan follows Medicare rules. Medicare rules say that TMS is covered for certain clinical indications. 
 
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 psychiatric TMS. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the enrollee had a Beck 
Depression Inventory II with a score of 31 on April 20, 2022. The enrollee had been tried on Lexapro 30 mg 
daily (8-2021), Wellbutrin 450 mg XL (6-2021), trazodone 300 mg (6-2021), Klonopin 1 mg (6-the 2021) and 
Geodon 80 mg (6-2021). This enrollee had been in therapy since 2017 with 364 sessions. This enrollee had a 
previous diagnosis of bipolar disorder. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychiatric TMS have not been met. Therefore, we decided that the Plan does 
not have to pre-approve psychiatric transcranial magnetic stimulation (TMS).