Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH level of care is the only 
option for a safe discharge for the enrollee. The Plan denied your request. The Plan says the enrollee does not 
meet all the requirements for an LTACH admission. 
 
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 that there are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the Plan. The Plan has approved ongoing care in the 
current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for labratory services provided on May 24, 2022. 
 
You asked the Plan to pay for labratory services. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for labratory services 
provided on May 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for labratory services provided on September 08, 2022. 
 
You asked the Plan to pay for labratory services. You say that you thought this would be covered. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for labratory services 
provided on September 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the office visit (99214) provided on  
October 6, 2022. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered 
benefit. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to issue reimbursement for the office visit (99214) provided on October 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the chiropractic manipulative treatments 
(98941) rendered by the out-of-network (OON) provider from September 21, 2022, through October 17, 2022. 
 
You asked the Plan to issue 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 the services were 
rendered by an out-of-network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to issue reimbursement care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to issue reimbursement for these services.  
 Therefore, we decided that the Plan does not have to issue reimbursement for the chiropractic manipulative 
treatments (98941) rendered by the out-of-network (OON) provider from September 21, 2022, through  
October 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for diagnostic tests provided on October 23, 
2022. 
 
You asked the Plan to waive the cost share for diagnostic tests. You say that you disagree with the cost share. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 10% coinsurance and a $800 deductible which applies to diagnostic 
tests.  
 
The item or service you asked the Plan to waive the cost share for falls within the diagnostic tests benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 10% 
coinsurance and a $800 deductible which applies to diagnostic tests. The total allowed amount for the 
diagnostic test is $59.01. You are being asked to pay a $5.90 towards your coinsurance ($59.01 x 10% = 
$5.90). You are being asked to pay $53.11 towards your $800 deductible. This cost sharing is a contractual 
obligation that had not been met at the time diagnostic tests was received on October 23, 2022. Therefore, we 
decided that the Plan does not have to waive the cost share for diagnostic tests provided on October 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 09, 2022. 
 
You asked the Plan to pay for an office visit. You say that this should be covered because the provider has a 
long-standing relationship with the enrollee. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 09, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 70140, 70220, 70320, 72052, 92512, and 92520 
provided on October 25, 2022. 
 
You asked the Plan to pay for codes 70140, 70220, 70320, 72052, 92512, and 92520. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 70140, 70220, 70320, 72052, 92512, and 92520 are not supported in the medical 
record. Specifically, the submitted medical records do not include interpretation and report of nasal function 
studies for the billed date of service. Therefore, code 92512 cannot be verified. 
 The medical records do not include interpretation and report of laryngeal function studies for the billed date of 
service. Therefore, code 92520 cannot be verified. 
 
The submitted medical records do not include interpretation and report of radiologic examination, teeth; 
complete, full mouth for the billed date of service. Therefore, code 70320 cannot be verified. 
 
The submitted medical records do not include interpretation and report of radiologic examination, facial bones; 
less than 3 views for the billed date of service. Therefore, code 70140 cannot be verified. 
 
The submitted medical records do not include interpretation and report of radiologic examination, spine, 
cervical; 6 or more views for the billed date of service. Therefore, code 72052 cannot be verified. 
 
The submitted medical records do not include interpretation and report of radiologic examination, sinuses, 
paranasal, complete, minimum of 3 views for the billed date of service. Therefore, code 70220 cannot be 
verified. 
 
Based on this information, we decided that Medicare rules for coverage of codes 70140, 70220, 70320, 72052, 
92512, and 92520 have not been met. Therefore, we decided that the Plan does not have to pay for codes 
70140, 70220, 70320, 72052, 92512, and 92520 provided on October 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an out-of-network outpatient surgery 
provided on August 30, 2022. 
 
You asked the Plan to waive the cost share for an out-of-network outpatient surgery. You say that you disagree 
with the cost share The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $750 deductible which applies to out-of-network outpatient surgery.  
 
The item or service you asked the Plan to waive the cost share for falls within the out-of-network outpatient 
surgery benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $750 deductible which applies to out-of-network outpatient surgery. You are being asked $750 towards 
your deductible. This cost sharing is a contractual obligation that had not been met at the time an out-of-
network outpatient surgery was received on August 30, 2022. Therefore, we decided that the Plan does not 
have to waive the cost share for an out-of-network outpatient surgery provided on August 30, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient diagnostic test provided on 
October 12, 2022. 
 
You asked the Plan to waive the coinsurance for an outpatient diagnostic test. You say that you disagree with 
the coinsurance.. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 50% 
coinsurance for outpatient diagnostic tests/outpatient hospital. 
 
You have been asked to pay 50% coinsurance for an outpatient diagnostic test. This item/service falls within 
the outpatient diagnostic tests/outpatient hospital 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 outpatient diagnostic test provided on October 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on January 20, 2022. 
 
You asked the Plan to pay for the diabetic supplies. You say that a referral was requested from the enrollees 
PCP. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the diabetic supplies 
provided on January 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on October 
26, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you feel that these services 
should be covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 one-way Medicare-covered ambulance services. 
 
You have been asked to pay a $350 copayment for ambulance services. This item/service falls within the one-
way Medicare-covered 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 services provided on October 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound provided on July 05, 2022. 
 
You asked the Plan to pay for an ultrasound. You say that the requesting provider should have requested 
authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an ultrasound provided 
on July 05, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test coded G0482 provided on October 24, 2022. 
 
You asked the Plan to pay for the drug test. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0482 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed. 
 We find that CPT code G0482 is not supported in the medical record. Specifically, the documentation shows 
that eight drug classes were tested. This means the documentation does not support 15-21 drug classes as 
required for the billing of this code. Based on this information, we decided that Medicare rules for coverage of 
the drug test have not been met. Therefore, we decided that the Plan does not have to pay for the drug test 
coded G0482 provided on October 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns on tooth #23, 24, and 26 (D6750) and a 
pontic on tooth #25 (D6240). 
 
You asked the Plan to pre-approve the crowns and pontic. You say that the teeth that would anchor the bridge 
are stable and there is no active periodontal disease. The Plan denied your request. The Plan says that the 
requested services are not medically necessary. 
 
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 the crowns 
and pontic 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 the crowns and pontic. Our reviewer 
says that that the coverage criteria has not been met. Our physician reviewer found that there is more than 50% 
bone loss on tooth #24.  It would be part of the requested bridge and is a compromised abutment that would 
likely lead to failure of the entire bridge over time. Even if there is no active periodontal disease, the existing bone loss is problematic enough to weaken the overall prosthesis.  A bridge should not be placed on teeth with 
inadequate supporting bone.  Placing a bridge on a periodontally compromised tooth would not meet the 
accepted standards of practice. 
 
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 the crowns and pontic have not been met. Therefore, we decided that the Plan 
does not have to pre-approve retainer crowns on tooth #23, 24, and 26 (D6750) and a pontic on tooth #25 
(D6240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0210) provided on 
October 24, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dentist visit was an emergency and the dental 
services provided were medically necessary. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the intraoral radiographic images are 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 requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral radiographic images (D0210) provided on October 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on October 05, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you feel the beneficiary should not 
aowe the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $10 
copayment for physician/practitioner services/primary care provider. 
 
You have been asked to pay a $10 copayment for an office visit. This item/service falls within the 
physician/practitioner services/primary care provider benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an office visit provided on October 05, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a denture repair, endosteal implant, and implant removal 
(D6100, D6010, D5611) provided on March 30, 2022. 
 
You asked the Plan to pay for the dental 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 do not fall 
within 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 pay for a denture 
repair, endosteal implant, and implant removal (D6100, D6010, D5611) provided on March 30, 2022.