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

 
We decided that the Plan does not have to pay for the post-stabilization care provided from July 12, 2022, to 
July 19, 2022. 
 
You asked the Plan to pay for the post stabilization care. You say that the medical records support the medical 
necessity of the services provided to the enrollee during these dates of service, and you request that the services 
be authorized and processed for payment. The Plan denied your request. The Plan says the enrollee's 
emergency medical condition stabilized by July 12, 2022, and subsequent care was post stabilization care, not 
approved in compliance with the health plan's authorization procedures. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post stabilization care. Our reviewer says 
that the post-stabilization care was not medically reasonable and necessary. Our physician reviewer found all 
inpatient care provided after July 12, 2022, through July 29, 2022, at the non-Plan facility was not needed on an 
emergent basis. Our reviewer also found that the treating physician did not document (in the physician notes, 
on a form, or in an order) that the enrollee was not stable for transfer as of July 12, 2022. 
 
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 post stabilization care have not been met. Therefore, we decided that the 
Plan does not have to pay for the post-stabilization care provided from July 12, 2022, to July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implant body (D6010) and bone grafts 
(D6104) for tooth #21, #22, #24, #25, and #27 provided on April 27, 2022, and June 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider called the Plan, and they were told 
the amount covered would be higher. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because any type of implant and all related services 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for surgical 
placement of implant body (D6010) and bone grafts (D6104) for tooth #21, #22, #24, #25, and #27 provided on 
April 27, 2022, and June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140), 
intraorifice barrier (D3911), and the pulp vitality tests (D0460 x 2) provided on July 25, 2022. 
 
You asked the Plan to pay 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. 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation-problem focused (D0140), intraorifice barrier (D3911), and the pulp vitality tests (D0460 x 2) 
provided on July 25, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridements and home visits provided on April 17, 
2021, and July 22, 2021. 
 
You asked the Plan to pay for the nail debridements and home visits. You say that you would like these 
services to be reconsidered for coverage. The Plan denied your request. The Plan says the enrollee was enrolled 
in hospice services on these dates of service; therefore, traditional Medicare is the primary payer for these dates 
of service. 
 
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 nail debridements and home visits provided on April 17, 
2021, and July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for bitewings (D0274) provided by an out-of-network 
provider on September 6, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like the Plan to pay 50% of the 
charges. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for bitewings (D0274) provided by an out-of-
network provider on September 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontic (D6245 x2) provided on May 12, 2022. 
 
You asked the Plan to pay for pontic. You say that you want the Plan to pay for the service. The Plan denied 
your request. The Plan says the service at issue is 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 pontic 
(D6245 x2) provided on May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified oral surgery procedure (D7999) provided on 
July 19, 2022. 
 
You asked the Plan to pay for an unspecified oral surgery procedure. You say that you want the Plan to pay for 
the service. The Plan denied your request. The Plan says the service at issue is 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 an 
unspecified oral surgery procedure (D7999) provided on July 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wound care visit provided on July 07, 2022. 
 
You asked the Plan to pay for a wound care visit. You say that this was medically necessary and should be 
covered, front end clerical staff were told to get the 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). There was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. Therefore, we decided that the Plan does not have to pay for a wound care visit provided on 
July 07, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the refraction. We decided that the Plan does not 
have to waive the copayment for the refraction.  
 
You asked the Plan to waive the copayment for the refraction provided on September 6, 2022. You say that you 
needed replacement lenses and the refraction was needed to determine if there had been refractive errors. The 
Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the copayment for the refraction.  
 
The record shows you received a refraction during a medical eye exam for pseudophakia. The Plan says you 
must pay a $45 copayment for the refraction. However, based on the plan contract, you cannot be asked to pay 
more than a $35 copayment for the refraction. Therefore, we decided that the Plan has to waive the copayment 
for the refraction.  
 
We also decided that the Plan does not have to waive the copayment for the refraction. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the refraction is received during a routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was provided due to a diagnosis of 
pseudophakia which makes the refraction medical in nature. Based on this information, we decided that the 
Plan's rules for coverage of the refraction have not been met. 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 the refraction. Therefore, we decided 
that the Plan does not have to waive the copayment for the refraction provided on September 6, 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: 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 the enrollee is stable and suitable for 
transfer to an LTACH. You say that the enrollee cannot be adequately care for in their current condition at a 
lower level of care and has failed outpatient treatment for the sinusitis. The Plan denied your request. The Plan 
says an LTACH admission is not medically necessary, and the enrollee can stay in the hospital until they are 
safe for transfer or discharge. 
 
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 the enrollee has had a complicated hospital course and has ongoing acute 
medical issues, requiring acute care services. The enrollee does not require services that they are not currently 
receiving but that would be available at the LTACH facility.  
 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (KO), single upright, thigh and calf, 
with adjustable flexion and extension joint (L1851). 
 
You asked the Plan to pre-approve a knee orthosis. You say that the enrollee is having surgery and the device is 
medically necessary for her post op care. The Plan denied your request. The Plan says your request is not 
medically necessary because the enrollee's records do not show she has had a recent injury or surgery of the 
knees or objective evidence of knee instability. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a knee orthosis. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not reveal objective physical exam evidence of right knee instability. 
There is no evidence of recent injury or surgery to the right knee. The enrollee is documented to be ambulatory 
however the criteria for the requested knee orthosis has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension 
joint (L1851).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 3, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 76705 is bundled into 
payment for code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 procedure code 76705 billed for date of service August 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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 June 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (ferric carboxymaltos). 
 
You asked the Plan to pre-approve Injectafer (ferric carboxymaltos). You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer (ferric carboxymaltos). Our 
reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our 
physician reviewer found the enrollee has a diagnosis of iron deficiency anemia with intolerance or 
unsatisfactory response to oral iron replacement. The documentation does not support that the enrollee has tried 
and failed Ferrlecit, Infed, or Venofer. The documentation does not support that Ferrlecit, Infed, or Venofer 
would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does 
not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer (ferric carboxymaltos) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Injectafer (ferric carboxymaltos).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 7, 2022 to July 
6, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 7, 2022 to July 6, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 14, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that this service didnt happen. 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 $30 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for a specialist visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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. There is medical documentation that states date of 
service was July 14, 2022. Therefore, we decided that the Plan does not have to waive the copayment for a 
specialist visit provided on July 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 20, 2022, billed with 
codes 81162, 81292, 81295, 81298, 81317, 81321 and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 20, 2022, billed with codes 81162, 81292, 81295, 81298, 81317, 81321 and 81351.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tissue debridement provided on April 19, 2022. 
 
You asked the Plan to pay for the tissue debridement. You say that the services should be paid. 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 tissue debridement 
provided on April 19, 2022.