Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on October 12, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that you would like the claim to be 
reprocessed and paid. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 
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 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 these items/services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on October 12, 2022, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on June 24, 2022. 
 
You asked the Plan to pay for radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 14, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for radiology services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for radiological services provided on June 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional hours for in-home support services. 
 
You asked the Plan to pre-approve additional hours for in-home support services. You say that you are 
requesting additional in-home support services hours due to medical issues preventing you from performing 
home tasks on your own. The Plan denied your request. The Plan says once the enrollee exhausts their 60 hours 
in the plan year, they will no longer be eligible to receive this benefit. 
 
Medicare does cover in-home support services. However, the Plan offers an in-home support services benefit 
that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a 
maximum of 60 hours per year trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, the Plan 
confirmed you have .95 hours available for in-home support service for the 2023 benefit year. After this time 
has been exhausted no additional hours will be covered. Therefore, we decided that the Plan does not have to 
pre-approve additional hours for in-home support services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the glasses provided on August 22, 2022. 
 
You asked the Plan to pay for the glasses. You say that you were not told the provider was out-of-network. You 
say you should be reimbursed the amount you paid out-of-pocket. The Plan denied your request. The Plan says 
the provider was out-of-network. 
 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 provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the glasses have not been met. Therefore, we 
decided that the Plan does not have to pay for the glasses provided on August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve more for an immediate maxillary and mandibular 
denture (D5130/D5140), and extractions (D7140). 
 
You asked the Plan to pre-approve more for the dental services. You say that you believe that the Plan should 
pay more. 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 pre-approve more for an immediate maxillary and 
mandibular denture (D5130/D5140), and extractions (D7140).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cancer screening (81479) provided on 
September 8, 2022. 
 You asked the Plan to pay for the hereditary cancer screening. You say that this test was performed by a 
certified laboratory at the request of the enrollee's treating physician. The Plan denied your request. The Plan 
says this test is not covered as a screening for an enrollee with no personal history of cancer. 
 
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. 
 
The test at issue in this appeal, the hereditary cancer screening, was requested solely for screening purposes. 
The records indicate that the enrollee has no personal history of cancer. Medicare does not cover this test solely 
for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cancer 
screening (81479) provided on September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on March 29, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that this provider has been in-
network for the last seven years. You say that the provider was listed on the Plan website as a network 
provider. You also say that the Plan needs to do a better job keep the current and updated information available. 
The Plan denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the office visit (99213) provided on March 29, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on May 
6, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99223 (1 unit) remains not supported. 
 
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, the CPT Code Manual definition of code 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provided records in this case 
do not document medical decision making of high complexity. Records document abnormal laboratory tests 
from which the patient had no acute symptoms; according to the American Medical Association CPT guide this 
would be classified as a low complexity problem. High risk of morbidity is not supported based on the 
asymptomatic history and review of systems and the essentially normal physical examination and the treatment 
plan of intravenous fluids and electrolyte replacement as documented. Given the lack of a high complexity 
problem and lack of high risk of morbidity, code 99223 is not supported in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on May 6, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for evoked potentials and reflex testing procedures provided on  
June 10, 2022. 
 
You asked the Plan to pay for evoked potentials and reflex testing procedures. You say that the services were 
medically necessary. The Plan denied your request. The Plan says that charges for or in connection with 
services or supplies that are, as determined by us, considered to be experimental or investigational are excluded 
from coverage under the members Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for evoked potentials and reflex 
testing procedures provided on June 10, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration, per site (D4265). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested items 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 requested items are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve biologic 
materials to aid in soft and osseous tissue regeneration, per site (D4265).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on August 23, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the provider must 
attempt to consult the attending or primary care physician about the services furnished and document the 
consent or declination date to consultations, and the date of consultations in the patients medical record. There 
was no documentation of contact in the patient record. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on August 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fungal infection polymerase chain reaction (PCR) panel 
provided on March 15, 2022. 
 
You asked the Plan to pay for a fungal infection PCR panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says PCR testing is not indicated as there are other appropriate means 
to verify fungal infection. 
 
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 pay for a fungal infection PCR panel. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the longstanding standard of care for the evaluation of fungus in toenails is the 
performance of both KOH and fungal culture on a toenail specimen. These laboratory tests are inexpensive, sensitive, and specific. It is unclear as to why this enrollees toenail required PCR testing as compared to KOH 
and fungal culture. Therefore, the PCR testing of this enrollees toenail was not medically reasonable or 
necessary at this time. 
 
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 fungal infection PCR panel have not been met. Therefore, we decided that the 
Plan does not have to pay for a fungal infection polymerase chain reaction (PCR) panel provided on March 15, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and anesthesia (D9215) 
provided on October 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied services because 
you needed the dental procedures done and cannot afford to pay out of pocket. The Plan denied your request. 
The Plan says your benefit for the limited oral evaluation has already been exhausted. Also, the denial of 
payment for the anesthesia 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. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the limited oral evaluation was exhausted on the date of service of May 3, 2022. The 
anesthesia is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to 
pay for a limited oral evaluation (D0140) and anesthesia (D9215) provided on October 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjustment to a partial denture (D5421) provided on 
November 16, 2022. 
 
You asked the Plan to pay for the dental service. You say that the providers office told you the dental service 
would be covered. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the adjustment to a partial denture is not covered by the Plan. Also, it was verified the Plan was never 
contacted to verify what dental services were covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
adjustment to a partial denture (D5421) provided on November 16, 2022.  
 Your complaint about the information given by the provider 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 the Cxbladder testing rendered on September 9, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. 
 
We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on September 9, 
2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a magnetic resonance imaging (MRI) of the abdomen with and without 
contrast provided on May 5, 2022. 
 
You asked the Plan to pay for the MRI. You say that the provider failed to get approval from the Plan and 
would like the MRI covered. The Plan denied your request. The Plan says that records do not support the 
reason the MRI of the abdomen was given. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the MRI of 
the abdomen was medically necessary. Our physician reviewer found that the enrollee has biopsy proven non-
alcoholic steatohepatitis (NASH) and since the diagnosis has been proven the enrollee is at risk for developing 
Hepatocellular carcinoma. The MRI is a highly sensitive screen for that tumor and as such was appropriate 
particularly considering the interim continued elevation of liver function tests. Thus, the MRI was reasonable 
considering the enrollee's primary diagnosis and clinical course. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pay for a 
magnetic resonance imaging (MRI) of the abdomen with and without contrast provided on May 5, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial mandibular denture (D5214), and a complete 
maxillary denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to approve these 
dentures. 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 December 13, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a partial mandibular denture (D5214), and a 
complete maxillary denture (D5110).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fungal infection polymerase chain reaction (PCR) panel 
provided on December 2, 2022. 
 
You asked the Plan to pay for the fungal infection PCR panel. You say that this procedure was ordered to 
hasten definitive diagnosis and to efficiently treat the enrollee's condition. The Plan denied your request. The 
Plan says PCR testing is not indicated as there are more appropriate means to verify fungal infection. 
 
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 pay for the fungal infection PCR panel. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the longstanding standard of care for the evaluation of fungus in 
toenails is the performance of both KOH and fungal culture on a toenail specimen. These laboratory tests are inexpensive, sensitive, and specific. It is unclear as to why this enrollees toenail required PCR testing as 
compared to KOH and fungal culture. Therefore, the PCR testing of this enrollees toenail was not medically 
reasonable or necessary at this time. 
 
 
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 fungal infection PCR panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the fungal infection polymerase chain reaction (PCR) panel provided on 
December 2, 2022.