Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on June 7, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises. You say that another claim for a different date of service, 
February 18, 2021, for the same procedure code (97110) was partially paid. The Plan denied your request. The 
Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to the services 
being rendered. The Plan also says that regarding the appellant's statement that the Plan paid for similar 
services rendered on February 18, 2021, they reviewed their records and determined that was due to an 
administrative error.  
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 therapeutic exercises (97110) provided on June 7, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on September 20, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it was medically necessary to treat the 
enrollee and you would like the services approved. The Plan denied your request. The Plan says the rendering 
provider is an out-of-network provider and there is no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home health visit provided on September 20, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) 
provider on November 24, 2021. 
 
You asked the Plan to pay 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 the service was 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 pay for 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) provider on  
November 24, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Outpatient diagnostic tests on October 30, 
2020. 
 
You asked the Plan to waive the copayment for Diagnostic tests. You say that you do not feel you should be 
responsible for the payment since you waited so long to be billed. The Plan denied your request. The Plan says 
that claim was processed appropriately. 
 
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 $100 
copayment for outpatient diagnostic procedures/tests. Since the allowable charges are less than your copayment 
amount, you are only responsible for $78.22 as your member responsibility on this claim. 
 
You have been asked to pay a $100 copayment for Diagnostic tests. Diagnostic tests fall within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for Outpatient diagnostic tests on October 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit with laboratory services (99213, 81003) 
provided on December 1, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit with laboratory services. You say that you have been told you 
were in-network, then not in-network, then in-network again, and you have no idea the status. The Plan denied 
your request. The Plan says This provider is not a network provider with the Plan, and they have also 
determined that these services are not  urgent or emergent, nor were they approved in advance. 
 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 an office visit with laboratory services (99213, 
81003) provided on December 1, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on May 5, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises. You say that a claim for a different date of service, 
February 18, 2021, for the same procedure code (97110) was partially paid. You also say the member received 
medically necessary services by your clinic, and you understand you are out of network. The Plan denied your 
request. The Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to 
the services being rendered. The Plan also says that regarding the appellant's statement that the Plan paid for 
similar services rendered on February 18, 2021, they reviewed their records and determined that the date of 
service, February 18, 2021, was paid due to an administrative error. 
 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 therapeutic exercises (97110) provided on May 5, 
2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
  You asked the Plan to pre-approve SNF services. You say that a fast appeal is requested due to recent 
hospitalization resulting in significant change in condition and urgent skilled therapy is necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the conditions for a skilled nursing facility stay. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation that the 
enrollee requires services on an inpatient basis, only in a skilled nursing facility setting. The records do not 
document the need for intravenous medications, new tube feeding, ostomy care or daily complex wound care. 
Services in the long-term care facility on a part time basis are appropriate in this case. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy. 
 
You asked the Plan to pre-approve medical nutrition therapy services. The Plan denied your request. The Plan 
says there is no physician order to establish medical necessity. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789-59) provided on March 26, 2021. 
 
You asked the Plan to pay for code 83789-59. 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 as billed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, Validity testing is an internal quality process to affirm that the reported results are 
accurate and valid, and thus is not a separately billable Medicare service. Based on this information, we 
decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, 
we decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789-59) provided on March 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740). 
 
You asked the Plan to pre-approve a crown. You say that the requested service is medically necessary. 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 pre-approve a 
crown (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve resin with predominantly base metal pontics (D6251) 
for teeth # 9 and 10. 
 
You asked the Plan to pre-approve the dental services. You say that you have a gap on the front of your teeth. 
You also say that you need your bridges to be repaired. The Plan denied your request. The Plan says resin with 
predominantly base metal pontics are not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested resin with predominantly 
base metal pontics are not among those covered under this benefit. 
 
Therefore, we decided that the Plan does not have to pre-approve resin with predominantly base metal pontics 
(D6251) for teeth # 9 and 10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 general dentist visits with a nonparticipating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you have been with this provider since 
2009. You say that your last appointment in the fall of 2021 had been covered. The Plan denied your request. 
The Plan says the medically necessary services are available in the service area with participating providers. 
 
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, dental services by a nonparticipating 
provider are not among those covered under this benefit. Additionally, the record shows that there are 
participating providers available to provide the requested services. Therefore, we decided that the Plan does not 
have to pre-approve 2 general dentist visits with a nonparticipating provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on May 12, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises. You say that a claim for a different date of service, 
February 18, 2021, and for the same procedure code (97110) was partially paid. The Plan denied your request. 
The Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to the 
services being rendered. The Plan also says that regarding the appellant's statement that the Plan paid for 
similar services rendered on February 18, 2021, they reviewed their records and determined that was due to an 
administrative error. 
 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 therapeutic exercises (97110) provided on May 
12, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on March 29, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises. You say that a claim for a different date of service, 
February 18, 2021, for the same procedure code (97110) was partially paid. The Plan denied your request. The 
Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to the services 
being rendered. The Plan also says that regarding the appellant's statement that the Plan paid for similar 
services rendered on February 18, 2021, they reviewed their records and determined that was due to an 
administrative error. 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 therapeutic exercises (97110) provided on March 
29, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies. 
 
You asked the Plan to pre-approve a continuous glucose monitor and supplies. You say that a continuous 
glucose monitor and supplies is medically necessary. The Plan denied your request. The Plan says all of the 
required coverage criteria for a continuous glucose monitor and supplies are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 Based on the records provided, you do not meet all of these criteria. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor and supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you were approved for a L4-L5 
transforaminal lumbar interbody fusion with instrumentation and will need inpatient admission after surgery 
The Plan denied your request. The Plan says there is no documentation provided to support the expectation you 
will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found you are approved for a L4-L5 transforaminal lumbar interbody fusion with 
instrumentation. The record does not document that the treating physician has a reasonable expectation of a 
length of stay spanning 2 or more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on May 26, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises. You say that a claim for a different date of service, 
February 18, 2021, for the same procedure (97110) was partially paid. The Plan denied your request. The Plan 
says this provider is out-of-network with the Plan, and authorization was not obtained prior to the services 
being rendered. The Plan also says that regarding the appellant's statement that the Plan paid for similar 
services rendered on February 18, 2021, they reviewed their records and determined that was due to an 
administrative error. 
 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 therapeutic exercises (97110) provided on May 
26, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on November 
7, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you had no one else to 
transport you so you needed to use the ambulance services. The Plan denied your request. The Plan says the 
copayment amount charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment per one-way trip for emergency ambulance services and non-emergency ambulance services.  
 
 
 
 
 
 You have been asked to pay a $225 copayment for ambulance services. Ambulance services falls within the 
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 November 7, 2021.