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

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99307) provided on 
August 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the provider relies on the facility staff to 
obtain the necessary authorizations. You say that these authorizations should cover medical treatments that are 
provided. You also say that the service was provided in good faith to the enrollee. The Plan denied your 
request. The Plan says 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 nursing facility is not a 
network provider either. The Plan did not pre-approve the item/service at issue. We found no exception that 
would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay 
for the subsequent nursing facility care (99307) provided on August 3, 2022, by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the comprehensive hearing test (92557), 
tympanometry and reflex threshold measurements (92550), and the evoked auditory test (92588) provided on 
July 20, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 $40 
copayment for each in-network Medicare-covered hearing exam.  
 
You have been asked to pay a $40 copayment for the in-network Medicare-covered hearing exam provided. 
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 the comprehensive hearing test (92557), tympanometry and 
reflex threshold measurements (92550), and the evoked auditory test (92588) provided on July 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the temporary replacement for patient owned equipment 
being repaired (CPT code K0462) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the DME. You say that the DME provider that is in-network stated they are 
no longer accepting new patients. The Plan denied your request. The Plan says there is an in-network provider 
that can perform the services the enrollee needs. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the temporary replacement for patient owned equipment being repaired (CPT code K0462) to be provided by 
an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic tooth #19 (D2740). 
 
You asked the Plan to pre-approve the crown - porcelain/ceramic tooth #19 (D2740). You say that the distal 
lingual cusp has broken off from the very large and leaking amalgam filling. The Plan denied your request. The 
Plan says this service is 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 crowns - 
porcelain/ceramic (D2740) 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 crown - porcelain/ceramic tooth #19 
(D2740). Our reviewer says that the service is not medically necessary. Our physician reviewer found tooth 
#19 presents with a two surface existing restoration, and caries on the occlusal and mesial. If needed, the tooth 
may be restored with a conventional filling material and does not need to be cut down for a full crown. In this 
instance there is sufficient structure to use a conventional restoration to restore the tooth.  Tooth #19 has a two surface restoration with what appears to be a mesial carious lesion, which would account 
for three surfaces involved. Our reviewer also found there does not appear to be any cusps involved. 
 
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 crown - porcelain/ceramic tooth #19 (D2740) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a crown - porcelain/ceramic tooth #19 (D2740).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia for procedures on the thorax (code 00400) provided on 
January 19, 2022. 
 
You asked the Plan to pay for anesthesia for procedures on the thorax. The Plan denied your request. The Plan 
says that this is a duplicate claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a claim for which this claim is a 
duplicate. Therefore, we decided that the Plan has to pay for anesthesia for procedures on the thorax  
(code 00400) provided on January 19, 2022.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are a paraplegic and require assistance to roll on 
your side every 2 hours for wound care. The Plan denied your request. The Plan says your condition does not 
meet criteria for SNF admission. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have identifiable skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. However, the enrollee 
does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. Admission to a 
SNF for inpatient skilled rehab services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power wheelchair provided on June 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a power wheelchair. You say that you did not know that the pharmacy was out-
of-network (OON). The Plan denied your request. The Plan says these services can be obtained from an in-
network provider. 
 
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 a power wheelchair provided on June 1, 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 the office visit (99202) provided from August 19, 2022, to 
August 22, 2022. 
 
You asked the Plan to pay for the chiropractic care. You say that you fell. You say that your primary care 
physician (PCP) strongly advised you see a chiropractor. You also say that you feel this should be covered. The 
Plan denied your request. The Plan says office visits performed by a chiropractor are not covered by Medicare 
or the Plan. 
 
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 pay for the office visit (99202) provided from August 19, 2022, to August 22, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy, outpatient medical nutrition, durable medical 
equipment, specialist visit, primary care physician visit, laboratory, emergency room, and telemedicine, 
diagnostic medical and urgent care services provided by multiple providers from August 14, 2020, to 
January 15, 2021. 
 
You asked the Plan to pay for psychotherapy, outpatient medical nutrition, durable medical equipment, 
specialist visit, primary care physician visit, laboratory, emergency room, and telemedicine, diagnostic medical 
and urgent care services. The Plan denied your request. The Plan says the claims processed correctly as the 
member has a primary insurance plan and this Plan is the members secondary insurance. The claims must be 
submitted to the members primary insurance first, therefore no adjustments are needed at this time. 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
an explanation of benefits from your primary insurance plan. As the secondary insurer, the Plan cannot be held 
responsible for psychotherapy, outpatient medical nutrition, durable medical equipment, specialist visit, 
primary care physician visit, laboratory, emergency room, and telemedicine, diagnostic medical and urgent care 
services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for psychotherapy, outpatient medical nutrition, durable medical equipment, specialist 
visit, primary care physician visit, laboratory, emergency room, and telemedicine, diagnostic medical and 
urgent care services provided by multiple providers from August 14, 2020, to January 15, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
June 10, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the service 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 subsequent nursing facility care (99308) provided on June 
10, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid, not otherwise 
specified (87500), culture, typing (87150), and infectious agent detection by nucleic acid, vancomycin 
resistance (87798) provided on November 27, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 infectious agent detection by nucleic acid, not otherwise 
specified (87500), culture, typing (87150), and infectious agent detection by nucleic acid, vancomycin 
resistance (87798) provided on November 27, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from June 25, 2021, to  
June 29, 2021. 
 
You asked the Plan to pay for inpatient hospital care. You say that hospice was revoked on June 25, 2021. The 
Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare 
covered services related or unrelated to the members terminal condition. The Medicare hospice benefit, 
through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of 
discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services 
and all care unrelated to the terminal illness until the first day of the month following the month in which 
hospice was revoked or discharged. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 25, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for inpatient hospital care 
provided from June 25, 2021, to June 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit and a radiologic examination, 
shoulder provided on August 26, 2021. 
 
You asked the Plan to pay for the emergency department visit and radiologic examination, shoulder. The Plan 
denied your request. The Plan says according to Medicare guidelines, an original claim submission must be 
filed to the appropriate Medicare claims processing contractor no later than 12 months, or 1 calendar year, after 
the date the services were furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department visit and radiologic examination, shoulder was not 
filed until October 4, 2022. This means that more than one calendar year from the date of service had passed 
before a claim was filed. Therefore, we decided that the Plan does not have to pay for an emergency 
department visit and a radiologic examination, shoulder provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for diagnostic procedure and test provided on 
June 23, 2022. 
 
You asked the Plan to waive the deductible for diagnostic procedure and test. You say that you are disputing 
the share cost. 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 
$236.29 deductible for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $236.29 deductible for diagnostic procedure and test. This item/service 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 deductible for diagnostic procedure and test provided on June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anterior resin-based composite of two surfaces (D2331), 
posterior resin-based composite of three surfaces (D2393), and posterior resin-based composite of two surfaces 
(D2392) provided on October 3, 2022. 
 
You asked the Plan to pay for the resin-based composites. You say that you were unaware these services would 
not be covered. You also say that you assumed the Plan would cover a service like this. The Plan denied your 
request. The Plan says you were not enrolled in the supplemental dental coverage at the time the restorative 
dental services in dispute were received. The Plan also says these services are not covered. 
 
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 
anterior resin-based composite of two surfaces (D2331), posterior resin-based composite of three surfaces 
(D2393), and posterior resin-based composite of two surfaces (D2392) provided on October 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on July 21, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you disagree with 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 $35 
copayment for physician/practitioner services/specialist services.  
 
You have been asked to pay a $35 copayment for specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 specialist office visit provided on July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist visit provided on June 27, 2022. 
 
You asked the Plan to pay for a specialist visit. You say that your prime care provider left, but you still needed 
this appointment and a test. 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 a specialist visit 
provided on June 27, 2022.