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

 
We decided that the Plan does not have to pay more for the retrograde filling (D3430) and apicoectomy 
(D3425) provided on October 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the retrograde filling and apicoectomy. You say that the primary payer's 
payment should cover the copayment. You also say that the secondary plan acts like a supplement to the 
primary plan. The Plan denied your request. The Plan says the coinsurance amount you are being charged is 
correct. 
 
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 Plan contract clearly states that you 
are responsible for a 20% coinsurance for non-Medicare covered comprehensive dental services that are 
rendered by an out-of-network provider. The record shows that these services were rendered by an OON 
provider, and you have been charged the correct amount. Therefore, we decided that the Plan does not have to 
pay more for the retrograde filling (D3430) and apicoectomy (D3425) provided on October 5, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visits provided from February 10, 2022, 
to August 11, 2022. 
 
You asked the Plan to reimburse you for the psychiatric services. You say that you were advised by a plan 
representative that the services would be covered under the out-of-network benefit. The Plan denied your 
request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment 
cannot be made for services that you receive from a provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
the office visits provided from February 10, 2022, to August 11, 2022.  
 
Your complaint about being misled by a plan representative is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80050, 81003, 82306, and 83036 provided 
on July 19, 2022. 
 
You asked the Plan to pay for procedure codes 80050, 81003, 82306, and 83036. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. You have requested payment for services billed under code 80050. Medicare does not cover or 
pay for services billed under this code.  
 
Medicare rules also say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. In this case, we have confirmed that code 81003 is a column II code to column I code 
81001. This claim has not been billed with an appropriate modifier to bypass the edit. 
 
Lastly, the rules also explicitly say that screening tests, with the exception of the few tests listed in the 
Medicare rules section, are not covered. The tests at issue in this appeal, 82306 and 83036, were requested 
solely for screening purposes. Medicare does not cover these tests solely for screening purposes. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 80050, 81003, 82306, and 83036 
provided on July 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on November 30, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. 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 office visit provided on 
November 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for methadone home treatments provided on September 26, 
2022. 
 
You asked the Plan to pay for methadone home treatments. 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 methadone home 
treatments provided on September 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on September 01, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this patient is in a facility and cannot choose 
where they go. We depend on facility staff to get these kinds of 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 laboratory testing 
provided on September 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic visit provided on December 14, 2022. 
 
You asked the Plan to pay for a chiropractic visit. You say that you were unaware that this provider was out-of-
network. 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 chiropractic visit 
provided on December 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on September 26, 2022. 
 
You asked the Plan to pay for laboratory testing. 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 laboratory testing 
provided on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic visit provided on December 08, 2022. 
 
You asked the Plan to pay for a chiropractic visit. You say that you were unaware that this provider was out-of-
network. 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 chiropractic visit 
provided on December 08, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three surgical implants. 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says only two implants are covered per year so the third implant will not be 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, certain limitations apply. The record 
shows only two implants are covered per year so the third implant will not be covered.. Therefore, we decided 
that the Plan does not have to pre-approve three surgical implants.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 20, 
2022, to June 23, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. 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 $390 
copayment for inpatient hospital care. 
 
You have been asked to pay a $390 copayment for inpatient hospital care. This item/service falls within the 
inpatient hospital care 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 inpatient 
hospital care provided on June 20, 2022, to June 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cataract surgeries provided on 
November 14, 2022, and November 30, 2022. 
 
You asked the Plan to waive the copayment for the cataract surgeries. You say that you cannot afford the 
copayments. 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 $225 
copayment for each in-network Medicare-covered outpatient surgery provided in an ambulatory surgical center.  You have been asked to pay a $225 copayment for each cataract surgery. These items/services fall within the 
outpatient surgery, including services provided in an ambulatory surgical center 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 the cataract surgeries provided on November 14, 2022, and 
November 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on October 
14, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. 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 $225 
copayment for outpatient surgery/. 
 
You have been asked to pay a $225 copayment for an outpatient surgery. This item/service falls 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 an outpatient surgery 
provided on October 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper and lower dentures (D5213 and D5214). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 20, 2021. 
Therefore, we decided that the Plan does not have to pre-approve upper and lower dentures (D5213 and 
D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic visit provided on December 15, 2022. 
 
You asked the Plan to pay for a chiropractic visit. You say that you were unaware that this provider was out-of-
network. 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 chiropractic visit 
provided on December 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 3, 
2022, to March 4, 2022. 
 
You asked the Plan to pay for SNF care. You say that services the member required and received are covered 
under the Medicare Act. The Plan denied your request. The Plan says services received do not meet Medicare's 
criteria for coverage. 
 
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. Additionally, 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. 
 
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 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 the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting.  
 
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. Additionally, the enrollee was under the Medicare 
hospice benefit for dates of service February 16, 2022, to March 4, 2022. These services are the responsibility 
of Original Medicare. Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
(SNF) care provided from February 3, 2022, to March 4, 2022.
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's ongoing medical needs 
requires an admission to an LTACH to achieve a safe and sustainable discharge. You say that the enrollee is 
stable and suitable to transfer to an LTACH. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee can safely receive the care they need in another setting. 
 
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 is improving and only requires short-term acute care at the current 
facility until they are more stable. The enrollee does not require services at the LTACH that are not already 
available at the current 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extraction of an erupted tooth (D7210) for tooth 
#17 and to pay for the removal of an impacted tooth (D7230) for tooth #32 provided by an out-of-network 
provider on December 13, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the surgeon did not know the tooth was 
impacted and it was medically necessary to complete the procedure. 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. Also, the denial of payment for the removal of an impacted tooth is 
correct because it is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for the extraction of an erupted tooth. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. The removal of an impacted tooth is not covered under the Plans dental benefit.  
Therefore, we decided that the Plan does not have to pay more for the extraction of an erupted tooth (D7210) 
for tooth #17 and to pay for the removal of an impacted tooth (D7230) for tooth #32 provided by an out-of-
network provider on December 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on June 2, 2022. 
 
You asked the Plan to pay for Guardant360 testing. You say that this testing should be covered. The Plan 
denied your request. The Plan says the enrollee has had previous treatment and therefore does not meet criteria 
for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that the enrollee must be the criteria listed in the rules 
section of this letter. 
 
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 Guardant360 testing. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that this enrollee had a pT1a tumor stated 
as perhaps even in-situ adenocarcinoma. Per the NCCN Guidelines for non-small cell lung cancer molecular 
profiling is not indicated. This testing is reserved for advanced disease. The service was not reasonable or 
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 Guardant360 testing have not been met. Therefore, we decided that the Plan 
does not have to pay for Guardant360 testing provided on June 2, 2022.