Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided 
April 21, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that this appeal should be granted because 
the services provided were medically necessary and meet all applicable professionally recognized standards of 
healthcare. The Plan denied your request. The Plan says there was not documentation of consultation with the 
attending or primary care physician in the enrollee's medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The submitted claim does not include a referring provider for the 
services at issue. Based on this information, we decided that Medicare rules for coverage of the psychotherapy 
services have not been met. Therefore, we decided that the Plan does not have to pay for the individual 
psychotherapy services (90832) provided April 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that further delay in care will have a detrimental effect on 
the enrollee's safety, ability to recover at the fullest extent, be discharged to a community setting and stay in 
that community setting, averting unplanned readmissions. The Plan denied your request. The Plan says the 
medical necessity criteria are not met for admission to acute inpatient rehabilitation. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for surgical repair of a femur fracture after a fall. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. There is not a reasonable 
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on January 
26, 2021. 
 
You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. Cardiovascular risk assessment panels are only 
covered for certain indications. 
 
While cardiovascular risk assessment panels are covered for certain indications, the file does not support that 
the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular risk assessment panel provided on January 26, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychotherapy visit provided by a psychology doctoral 
(Psy.D) practitioner on April 21, 2021. 
 
You asked the Plan to pay for psychology visit. You say that your provider rendered medically necessary 
services to the enrollee in good faith. The Plan denied your request. The Plan says the denial of payment for 
this service is correct, because there was no documented contact with the enrollee's attending or primary care 
physician. 
 
The Plan must follow Medicare rules. Medicare rules say that for coverage of services provided by a 
psychology doctoral practitioner, the provider must attempt to consult the enrollee's attending or primary care 
physician about services.  
 
We looked at the file and Medicare rules. The record does not show a consultation or attempt to consult the 
enrollee's attending or primary care physician prior to rendering service. Based on this information, we decided 
that Medicare rules for coverage of psychology visit have not been met. Therefore, we decided that the Plan 
does not have to pay for a psychotherapy visit provided by a psychology doctoral (Psy.D) practitioner on April 
21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the lower extremity orthosis you received 
on November 10, 2020. 
 
You asked the Plan to waive the coinsurance for the lower extremity orthosis. You say that you were told that 
you hit your out-of-pocket maximum. The Plan denied your request. The Plan says at the time you received 
these items, you had only met $4054.39 towards your out-of-pocket maximum. 
 
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 20% 
coinsurance for prosthetic devices and medical supplies.  

You have been asked to pay 20% coinsurance for the lower extremity orthosis. The lower extremity orthosis 
falls within the prosthetic devices and medical 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 coinsurance for the lower extremity orthosis you received on November 10, 2020.  
 
Your complaint about being given incorrect information about your out-of-pocket maximum 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain (D9110) 
provided on May 28, 2021. 
 
You asked the Plan to pay for the palliative (emergency) treatment. You say that you would like to appeal this 
service. The Plan denied your request. The Plan says this service is not a covered expense under your dental 
plan. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
palliative (emergency) treatment of dental pain (D9110) provided on May 28, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you have completed your intensive course of care at the inpatient rehab 
facility and intermittent therapy can safely be received at a different setting, for example, home with home 
health or outpatient therapy in residential care. 
 
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 that your condition does not meet 
Medicare criteria for SNF services. 
 
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 skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for speech therapy services you received from 
April 22, 2021, to May 18, 2021. 
 
You asked the Plan to waive the copayment for the speech therapy services. You did not provide an argument 
in your appeal request. The Plan denied your request. The Plan says you were charged these copayments 
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 $25 
copayment for speech therapy services.  
 
You have been asked to pay a $25 copayment for the speech therapy services. 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 speech therapy services you received from April 22, 2021, to May 18, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for spirometry provided on May 13, 2021. 
 
You asked the Plan to waive the copayment for spirometry. You say that you disagree with the additional 
charge for spirometry. The Plan denied your request. The Plan says the claims were processed correctly and 
you are being charged the correct amount. 
 
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 $90 
copayment for breathing capacity tests.  
 
You have been asked to pay a $90 copayment for spirometry. Spirometry 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 copayment 
for spirometry provided on May 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) you had on 
March 30, 2021. 
 
You asked the Plan to waive the copayment for the EKG. You say that you were not charged for this same 
service when you had it in 2020. The Plan denied your request. The Plan says you were charged this copayment 
correctly.  The Plan says that because the allowed amount for this service ($14.80) is less than your copayment 
obligation, you are responsible for the full allowed amount. 
 
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 diagnostic procedures and tests (including EKGs).  
 
You have been asked to pay a $100 copayment for the EKG. The EKG falls within the diagnostic procedures 
and tests benefit category. This copayment applies regardless of what you may have paid in previous years. 
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 electrocardiogram (EKG) you had on March 30, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the extremity study (93970) provided on April 8, 2021. 
 
You asked the Plan to pay for the extremity study. You say that you would like this claim to be reprocessed for 
payment. The Plan denied your request. The Plan says the diagnosis Z03.89 is not a covered diagnosis for 
procedure 93970, per the Medicare Local Coverage Article. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate Current Procedural Terminology (CPT) code. 
 
In this case, the CPT Code Manual definition of code 93970 is an extremity study. 
 
We find that CPT code 93970 is not supported in the medical record. Specifically, diagnosis code Z03.89 is not 
listed as a medically necessary code in which CPT 93970 is covered in the Local Coverage Article (LCA) 
A52993. Based on this information, we decided that Medicare rules for coverage of the extremity study have 
not been met. Therefore, we decided that the Plan does not have to pay for the extremity study (93970) 
provided on April 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA 1 and BRCA 2 testing. 
 
You asked the Plan to pre-approve the testing. The Plan denied your request. The Plan says this testing is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that BRCA testing is covered for the indications 
established in the applicable LCD. 
 
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 testing. Our reviewer says that the 
requested testing is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee is a 67-year-old enrollee adopted with an unknown family history. Provider requesting BRCA testing 
for this enrollee with invasive ductal carcinoma with high-grade DCIS, estrogen/progesterone positive and 
HER-2/neu positive diagnosed at age 63. The LCD states that Medicare will cover BRCA-testing for an 
adopted individual with breast cancer diagnosed at less than or equal to 50 years old, that is suspicious of being 
a BRCA-related cancer. Individuals with limited family history/structure, defined as fewer than 2 females first- 
or second-degree relatives having lived beyond age 45 in either lineage may also be eligible for BRCA gene 
testing. Similar to all testing, these situations require explanation of medical necessity for BRCA testing in the 
patient's medical record, and documentation of genetic counseling prior to BRCA testing. The review has 
determined that the requested genetic testing is not medically reasonable and necessary according to the 
coverage criteria established in the LCD. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve BRCA 1 and BRCA 2 testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist services provided from May 12, 
2021, to August 24, 2021. 
 
You asked the Plan to waive the copayments for specialist services. You say that you were not aware that you 
would be seeing a physician's assistant instead of a doctor and feel that you should not have to pay a specialist 
copayment when you did not see a physician. The Plan denied your request. The Plan says the claims were 
processed correctly, and you are being charged the correct amount. 
 
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 $20 
copayment for specialist visits. 
 
The medical records show that you received specialist services from May 12, 2021, to August 24, 2021, for a 
total of 3 visits. Therefore, you are responsible to pay a $20 copayment per each visit. The total amount you 
owe is: $60.   
 
You have been asked to pay the total copayment amount of $60 for specialist services. Specialist services fall 
within the physician/practitioner services, including doctor's 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. Therefore, we decided that the Plan 
does not have to waive the copayments for specialist services provided from May 12, 2021, to August 24, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on June 10, 2021. 
 
You asked the Plan to pay for the dental item. You say that the guard is being used to cover the space where 
you had a tooth extracted. You say that the guard will prevent tooth # 15 from dropping down into the space. 
You also say that the guard will help preserve your overall health and structure of your remaining teeth. The 
Plan denied your request. The Plan says the occlusal guard is not listed as a covered dental item. 
 
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 occlusal guard is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal guard 
(D9944) provided on June 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapy assistant on August 24, 2020. 
 
You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate if services are not available from preferred providers. You 
say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your 
request. The Plan says the records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant 
(OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, 
because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy 
services provided by an occupational therapy assistant on August 24, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) and core build up (D2950) provided on 
January 30, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says the crown is not listed as a covered service. The Plan also says core build up is not 
listed as a covered service either. 
 
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 crown and core build up are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740) and core build up (D2950) provided on January 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine and vaccine administration provided 
January 13, 2021. 
 
You asked the Plan to pay for the shingles vaccine services. You say that you would like these claims 
reprocessed and approved for payment. The Plan denied your request. The Plan says this vaccine is not among 
those covered under the medical benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine services. Therefore, we decided that the Plan does not have to pay for the shingles vaccine and vaccine 
administration provided January 13, 2021.  
 
Benefits for the shingles vaccine services may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the comprehensive oral evaluation, complete series of 
intraoral x-rays, prophylaxis, and topical application of fluoride varnish provided on June 16, 2021, by an OON 
provider. 
 
You asked the Plan to pay more for the comprehensive oral evaluation, complete series of intraoral x-rays, 
prophylaxis, and topical application of fluoride varnish. You say that prior to receiving these services you 
asked the dentist's staff member if they accepted your insurance, and you were told yes. You also say that you 
should not have to pay anything since the provider's staff did not do their job correctly. The Plan denied your 
request. The Plan says these services were rendered by an OON provider. 
 
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, you are responsible for the difference 
between the billed amount and allowed amount for covered dental services that are received OON. Therefore, 
we decided that the Plan does not have to pay more for the comprehensive oral evaluation, complete series of 
intraoral x-rays, prophylaxis, and topical application of fluoride varnish provided on June 16, 2021, by an OON 
provider.