Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202), x-ray exam of the lumbar spine 
(72100), and the x-ray exam of the thoracic spine (72070) provided on October 1, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered by the Plan 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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99202), x-ray exam of the lumbar spine (72100), and the 
x-ray exam of the thoracic spine (72070) provided on October 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L0456) provided February 25, 2022. 
 
You asked the Plan to pay for the orthosis. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. Insufficient clinical records were provided to support this 
item. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for an orthosis (L0456) provided February 
25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, of an erupted tooth or exposed root (D7140) 
provided on October 4, 2022. 
 
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. 
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction, of 
an erupted tooth or exposed root (D7140) provided on October 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing (83789) billed for date of service August 4, 
2022. 
 
You asked the Plan to pay for validity testing. You say that the services at issue have been billed correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
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 validity testing 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 validity testing (83789) billed for date of service August 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychiatric hospital care. 
 
You asked the Plan to pre-approve psychiatric hospital care. You say that psychiatric hospital care is medically 
necessary. The Plan denied your request. The Plan says the patient can be safely managed on an outpatient 
basis by beginning visits with a psychiatrist to review/optimize pharmacotherapy begun in the hospital. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 psychiatric hospital care.  Our reviewer says that psychiatric hospital care is not medically necessary in this case. Our physician reviewer 
found that based upon review the records provided for the dates in question, you were not showing any 
dangerousness to self or others and not showing any perceptual disturbance, psychosis or aggressive behaviors. 
The records did not show any treatment failure on an outpatient basis and there was no documentation that you 
are not able to function. It did not appear medically necessary and reasonable to have psychiatric care provided 
at the partial hospitalization level of care rather than a lower level of care beyond the dates in question as you 
did not have any suicidal or homicidal thoughts or behavioral disturbance. You did not appear to require partial 
hospitalization treatment for the dates in question as you were not showing any psychological or psychiatric 
illness and did not require this intensity of treatment. Based upon review the records provided, you do not meet 
the criteria for treatment at partial hospitalization level of care and could have been treated in a lesser restrictive 
setting as you were not showing any suicidal or homicidal ideation and were not showing any psychosis or 
aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychiatric hospital care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve psychiatric hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve more than six therapeutic massage therapy visits. 
 
You asked the Plan to pre-approve more than six therapeutic massage therapy visits. You say that you feel that 
receiving massage therapy more often than every other month would benefit you. The Plan denied your 
request. The Plan says the requested services for greater than six (6) massage therapy visits is not covered. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. However, 
your plan offers a supplemental benefit for therapeutic massage services. Your contract does not allow for more 
than six massage visits per calendar year. The record shows that as of December 12, 2022, you had used five 
massage therapy visits, and had one visit remaining. Therefore, we decided that the Plan does not have to pre-
approve more than six therapeutic massage therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair lift. You say that you would like reconsideration because the 
requested stair lift is medically necessary. The Plan denied your request. The Plan says the requested stair lift is 
not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that this item is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been 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. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0554).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on May 24, 2022. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that we depend upon the facility staff to 
verify eligibility and to obtain authorization. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a skilled nursing facility 
visit provided on May 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 09, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says it is important to know which providers are part of our network because, with 
limited exceptions, while the enrollee is a member of our plan, they must use network providers to get their 
medical care and services. The only exceptions are emergencies, urgently needed services when the network is 
not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which 
Molina Medicare Choice Care (HMO) authorizes use of out-of-network providers. 
 
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 office visit provided on August 09, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, chest, single view (code 71045) 
provided on May 24, 2022. 
 
You asked the Plan to pay for radiologic examination, chest, single view. 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 June 3, 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 radiologic examination, chest, single view have not 
been met. Therefore, we decided that the Plan does not have to pay for radiologic examination, chest, single 
view (code 71045) provided on May 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 07, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on March 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periapical x-ray provided by a participating provider on 
July 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were never told you would have an x-ray 
done. 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 November 9, 2022. 
Therefore, we decided that the Plan does not have to pay for a periapical x-ray provided by a participating 
provider July 13, 2022.  
 
The claim for the paid DOS was processed prior to the claim for the DOS at issue.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain fused to predominantly base metal 
tooth #'s 8 and 9 (D2751). 
 
You asked the Plan to pre-approve the crown - porcelain fused to predominantly base metal tooth #'s 8 and 9 
(D2751). You say that the service is medically necessary. The Plan denied your request. The Plan says this 
service is not medically necessary. 
 
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. The Plan covers the crown - 
porcelain fused to predominantly base metal tooth #'s 8 and 9 (D2751) when the services are medically 
necessary and reasonable.  
 
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 crown - porcelain fused to 
predominantly base metal tooth #'s 8 and 9 (D2751).  Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation 
of the completed root canals on tooth #'s 8 and 9 are required prior to the approval for coverage for crown 
restorations for tooth #'s 8 and 9. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown - porcelain fused to predominantly base metal tooth #'s 8 and 9 
(D2751) have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown - 
porcelain fused to predominantly base metal tooth #'s 8 and 9 (D2751).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve specialist office visit. You say that the enrollee needs to see the provider 
due to medical complexity. The Plan denied your request. The Plan says the service can be provided by an in-
network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92004) and a determination of 
refractive state (92015) provided on December 9, 2021. 
 
You asked the Plan to pay for a medical eye examination (92004) and a determination of refractive state 
(92015). You say that the claim was incorrectly denied claiming that you saw an out-of-network provider. You 
also say that this is false. The Plan denied your request. The Plan says this benefit has been exhausted. 
 
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 services are provided by an in-network Plan specific vision 
network provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that they will cover up to $75 for an out-of-
network routine eye examination (including refraction and dilation). The record shows that even though the 
provider is in-network with the Plan, the provider is not in-network with the Plan specific vision network 
provider. Based on this information, we decided that the Plan's rules for coverage of a medical eye examination 
(92004) and a determination of refractive state (92015) have not been met. Therefore, we decided that the Plan 
does not have to pay for a medical eye examination (92004) and a determination of refractive state (92015) 
provided on December 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88361-59, 88312-XE, 88305-XE, and 
88112 billed for date of service March 28, 2022. 
 You asked the Plan to pay for procedure code(s) 88361-59, 88312-XE, 88305-XE, and 88112. You say that you 
disagree with the denial. The Plan denied your request. The Plan says this code is included in the skilled 
nursing facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT code 88361-59, 88312-XE, 88305-XE, and 88112 has a Professional/Technical indicator of 1. 
This means that CPT code 88361-59, 88312-XE, 88305-XE, and 88112 has both a professional and technical 
component. In this case, CPT code 88361-59, 88312-XE, 88305-XE, and 88112 has not been billed with an 
appropriate modifier to indicate the professional component. Based on this information, we decided that 
Medicare rules for coverage of procedure code 88361-59, 88312-XE, 88305-XE, and 88112 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code(s) 88361-59, 88312-XE, 88305-
XE, and 88112 billed for date of service March 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 8, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air 
mileage (A0436) provided on May 29, 2021. 
 
You asked the Plan to pay for rotary wing air transport and mileage. You say that your company was having 
system issues and has been short of staff which is why you have not been able to submit claims in a timely 
manner. The Plan denied your request. The Plan says this claim was not received until August 12, 2022. The 
Plan also says that the claim was untimely, and the submission did not meet the exception criteria guidelines 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for rotary wing air transport and mileage was not filed until August 12, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary 
wing air mileage (A0436) provided on May 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from August 4, 2022, to 
August 7, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that the potassium was administered via 
intravenous drip because your potassium level was so low. The Plan denied your request. The Plan says self-
administered drugs are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are 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 drugs 
provided from August 4, 2022, to August 7, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.