Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specimen validity testing provided to the enrollee on April 
19, 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 the code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for specimen validity testing provided to the enrollee on April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tetanus and diphtheria toxoids adsorbed (Td) vaccine 
(90714) and administration (90417) provided on May 12, 2022. 
 
You asked the Plan to pay for the vaccine. You say that your doctor advised you were due for a tetanus shot. 
You say that you were not advised this would not be covered by your insurance. The Plan denied your request. 
The Plan says the tetanus vaccine is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for Tetanus and diphtheria toxoids adsorbed (Td) 
vaccine (90714) and administration (90417) provided on May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943) 
provided on December 31, 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 this service is not a covered benefit under the 
enrollees contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 
 The records show that the service provided does not meet Medicare criteria for coverage of chiropractic 
services and therefore, is not covered under the Plans contract. Therefore, we decided that the Plan does not 
have to pay for the extraspinal chiropractic manipulative treatment (98943) provided on December 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit (99336) provided on May 18, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the rest home visit. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and 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 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 rest home visit (99336) provided on May 18, 
2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 77067-26 billed for date of service October 18, 2021. 
 
You asked the Plan to pay for code 77067-26. You say that the patient had multiple exams on this date of 
service. 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 December 29, 2021. 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 code 77067-26 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 77067-26 billed for date of service October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 provided on June 20, 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 an office visit provided on July 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee could not see another provider since no 
one was allowed into the office. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no 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 an office visit provided on July 1, 2022, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Minuteman at L2/3. 
 
You asked the Plan to pre-approve Minuteman at L2/3. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Minuteman at L2/3. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the request in this clinical scenario is a stand-alone procedure and therefore, is not 
indicated. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Minuteman at L2/3, in this case, is 
not medically reasonable or 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 Minuteman at L2/3 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Minuteman at L2/3.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drug (A9270) provided on June 7, 
2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not covered under your contractual 
policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug provided is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drug 
(A9270) provided on June 7, 2022.  
 Benefits for this item 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 for the refraction provided on May 14, 2022. 
 
You asked the Plan to pay for the refraction. You say that you had a routine eye exam, and it should be 
covered. You say the vitreous degeneration diagnosis was a byproduct of the routine screening. The Plan 
denied your request. The Plan says the eye refraction is only covered during a routine eye exam. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the Plan covers eye refractions during a routine exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not performed during a routine eye 
exam. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been 
met. Therefore, we decided that the Plan does not have to pay for the refraction provided on May 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on March 31, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you are appealing the denied claim. The 
Plan denied your request. The Plan says the rendering provider is an OON provider and there was no 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 the outpatient services provided on March 31, 
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 the observation care services provided on May 11, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the observation care services. You say that the claim should be paid without a 
referral, and you would like the claim to be reprocessed for payment. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was 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 the observation care services provided on May 11, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection services (87798, 87481) provided 
on May 4, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the infectious agent detection services. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they were non-emergent and 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 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 infectious agent detection services (87798, 87481) 
provided on May 4, 2022 by an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation on tooth 
#14 and guided tissue generation, natural teeth - resorbable barrier on tooth #14. 
 
You asked the Plan to pre-approve bone replacement graft for ridge preservation on tooth #14 and guided tissue 
generation on tooth #14. You say that the services are necessary. The Plan denied your request. The Plan says 
the requested services are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
replacement graft for ridge preservation on tooth #14 and guided tissue generation, natural teeth - resorbable 
barrier on tooth #14.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on March 29, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital services. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
were non-emergent and 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 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 outpatient hospital services 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 a radiation oncology treatment provided on May 23, 2022, 
by an OON provider. 
 
You asked the Plan to pay for a radiation oncology treatment. You say that the services were rendered in good 
faith and medically necessary. The provider depends upon the hospital staff to verify eligibility and to obtain 
the proper authorization from the enrollee's insurance. 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 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 radiation oncology treatment provided on May 
23, 2022, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 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 does not have documented skilled nursing or skilled therapy needs. Daily 
skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of 
the enrollees condition. The enrollees care needs, custodial and intermittent, can, as a practical matter, be 
provided at a lower level of care. 
 
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. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the comprehensive hearing test (92557) 
provided on May 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to waive the coinsurance for the comprehensive hearing test. You say that you always pay a 
copay of $45, but are being charged an additional $14.52. You also say that you feel you should not have to 
pay this. 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 40% 
coinsurance for out-of-network Hearing services.  
 
You have been asked to pay a 40% coinsurance for the comprehensive hearing test. This item/service falls 
within the out-of-network Hearing 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 coinsurance 
for the comprehensive hearing test (92557) provided on May 16, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services provided to the enrollee on March 22, 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 that the situation does not meet any of the criteria listed for these services. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 services. Our reviewer says that the services at issue in this case were medically reasonable or 
necessary. Our physician reviewer found that the enrollee had a history of hypertension and chronic left knee 
pain. The enrollee sought ambulance services for transport after he knee gave out and the enrollee had pain 
with ambulation. The review has determined that the enrollees presenting symptoms met prudent layperson 
criteria for emergency care. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
ambulance services provided to the enrollee on March 22, 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.