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

We decided that the Plan does not have to pay for lab services provided on March 29, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for the lab services. You say that the patient's specimen was sent in by the member's referring physician. The Plan denied your request. The Plan says 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.

Neither the provider of the lab services in this case nor the referring provider is 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 lab services provided on March 29, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services billed with code A0425-U8 for dates of 
service October 2, 2021, to October 16, 2021. 
 
You asked the Plan to pay for code A0425-U8. You say that these services were medically necessary and 
should be covered. The Plan denied your request. The Plan says you did not bill code A0425 correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the U8 modifier is non-covered for Medicare 
services.  You billed code A0425 with a U8 modifier, which is why this particular code cannot be paid as 
billed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code A0425-U8 have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services billed with code A0425-U8 billed for dates of service October 2, 2021, to October 16, 
2021.  
 Therefore, we decided that the Plan does not have to pay for ambulance services billed with code A0425-U8 
for dates of service October 2, 2021, to October 16, 2021.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health rehabilitation services. 
 
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says that 
there are no skilled needs identified that require a licensed therapist in the home. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the home health physical therapy (PT) visits are reasonable and necessary. Our physician reviewer 
found the clinical documentation shows that you are clearly home bound. Our reviewer also found that the 
evaluating therapist documents complex functional impairments, thus 9 home health PT visits are medically 
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 home health services have been met. Therefore, we decided that the Plan has to 
pre-approve home health rehabilitation services.  
 
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 pay for the osseous surgery (D4260) provided by an out-of-network 
provider on April 4, 2022. 
 
You asked the Plan to pay for the osseous surgery (D4260). You say that you are appealing the $2,900 payment 
for the outpatient dental surgery. The Plan denied your request. The Plan says the service was not performed in 
conjunction with accidental injury and ineligible for coverage. 
 
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 osseous surgery (D4260) is not 
among those covered under the benefit or medical benefits. Therefore, we decided that the Plan does not have 
to pay for the osseous surgery (D4260) provided by an out-of-network provider on April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99050 billed for date of service May 7, 2022. 
 
You asked the Plan to pay for procedure code 99050. You say that you have provided documentation of the 
diagnosis code, so this claim should be paid. The Plan denied your request. The Plan says procedure code 
99050 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99050 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99050 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99050 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99050 billed for date of service May 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for an amalgam filling on tooth #14 (D2160) 
provided on June 2, 2022. 
 
You asked the Plan to reduce the cost share for a filling. You say that the dental services were preventive. 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 50% coinsurance for a filling after the $100 deductible has been met for basic dental services. The contract also says 
that fillings covered once every 24 months per surface, per tooth. White fillings on posterior teeth will be 
processed as a silver filling and the patient is responsible for up to the contracted fee. 
 
You have been asked to pay the remaining deductible amount of $81 ($147 original allowed amount - $81 
deductible paid = $66). You have also been asked to pay $33, which is 50% coinsurance of the remaining 
allowed amount for a filling ($66 remaining allowed amount x 50% coinsurance = $33). You have been asked 
to pay the difference between the allowed amounts for a resin-based composite filling and an amalgam filling 
($208 - $147 = $61). You have been asked to pay a total of $175 ($81 deductible + $33 coinsurance + $61 
difference between allowed amount = $175). This item/service falls within the dental 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 reduce the cost share for an amalgam filling on tooth #14 (D2160) provided on June 
2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on June 
30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the panoramic 
radiographic image was not covered. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a panoramic radiographic image (D0330) provided on June 30, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are asking for the stay to be covered. The Plan 
denied your request. The Plan says you have exhausted the Plan's SNF benefit period. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from May 30, 2022, to 
September 16, 2022. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve a continuation of SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 69990 and 20936 billed for date of service 
April 14, 2022. 
 
You asked the Plan to pay for codes 69990 and 20936. You say that the Plan's denial is not correct. The Plan 
denied your request. The Plan says code 20936 is not separately payable and payment for code 69990 is 
bundled into payment for code 22633. 
 
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 69990 
is a column II code to column I code 22633 with a modifier indicator of 0. The column II code is therefore not 
payable. In addition, we find that procedure code 20936 has a status indicator of B on the Physician Fee 
Schedule. This means that procedure code 20936 is not separately payable. 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 codes 69990 and 20936 billed for date of service April 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is a great facility where you are comfortable that 
you will receive great care and is close to family where you can be visited. The Plan denied your request. The 
Plan says the criteria for admission to the Acute Inpatient Rehabilitation setting have not been met. Your 
ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be 
provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit under the enrollee's 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Injectafer 750mg/15ml solution (J1439). 
 
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet step therapy criteria for 
coverage of the requested medication. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 this medication. Our reviewer says that 
the enrollee does not meet step therapy criteria for coverage of the requested medication. Our physician 
reviewer found that the Plan requires a trial of the drug Ferrlecit, Infed, or Venofer before they will approve the 
requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no 
documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely 
have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Injectafer 750mg/15ml solution (J1439).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) provided 
March 21, 2022. 
 
You asked the Plan to pay for the SelectMDx test. You say that the test was requested directly from the treating 
physician who makes the professional determination of diagnosis and medical necessity to successfully treat 
the enrollee. The Plan denied your request. The Plan says the request is not medically necessary under 
Medicare as the member did not have any signs or symptoms to indicate these tests were medically necessary 
and the testing is not being used to manage or treat a specific medical problem or diagnosis. 
 
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 genetics testing provided is not FDA approved for cancer 
management. The records are from an office visit dated June 17, 2021. The requisition form is signed and dated 
9 months after this visit on March 22, 2022. Based on this information, we decided that Medicare rules for 
coverage of the SelectMDx test have not been met. Therefore, we decided that the Plan does not have to pay 
for the unlisted molecular pathology procedure (81479) provided March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) and complete lower 
denture (D5120) provided on April 29, 2022. 
 
You asked the Plan to pay for the dentures. You say that you got new dentures last year. You say that you 
could not wear them. You say that you had to wear your old dentures. You say that you were hoping to have 
the newer dentures fixed. You also say that the dental office ended up just making new ones. The Plan denied 
your request. The Plan says your benefit for the dentures 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 August 5, 2021. 
Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) and complete 
lower denture (D5120) provided on April 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36005 billed for date of service January 12, 
2022. 
 
You asked the Plan to pay for procedure code 36005. You say that this service was medically necessary and 
billed appropriately. The Plan denied your request. The Plan says payment for code 36005 is bundled into 
payment for code 75827-26. 
 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 36005 
is a column II code to column I code 75827-26. 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 36005 billed for date of service January 12, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-ray (code D0274) you received on June 7, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you had an abscessed tooth and the dentist took 
an x-ray before they could extract it. You feel it is the first dentist's fault and you should not have to pay for 
this x-ray. 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. Your Plan only covers one 
bitewing x-ray per year.  You already received a covered x-ray on April 22, 2022.  This limitation applies 
regardless of the reason for the x-ray. 
 
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 April 22, 2022. Therefore, we decided that the Plan does not have to pay for the bitewing x-ray (code D0274) you received on 
June 7, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing (81455) billed for date of service April 25, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says that the date of service for a clinical 
laboratory test or the technical component of physician pathology service must be the date the specimen was 
collected. The specimen was collected on March 24, 2022, rather than the billed date of service April 25, 2022. 
 
The Plan must follow Medicare rules. The rules say that generally, laboratory services should be reported with 
the date of specimen collection as the date of service; however, there are three exceptions to this rule. The rules 
also 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 acknowledged nor addressed the exceptions to the 
rule applied. The test in this case was performed on a solid tumor specimen which was collected in a hospital 
setting as part of a surgical procedure. It is very likely that an exception to the general rule has been met in this 
case, which would mean that the correct date of service would be the date the testing was performed. 
Therefore, we decided that the Plan has to pay for laboratory testing (81455) billed for date of service April 25, 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93320 billed for date of service March 9, 2022. 
 
You asked the Plan to pay for code 93320. You say that the records support the charges billed. The Plan denied 
your request. The Plan says payment for code 93320 is bundled into payment for code 93306. 
 
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 93320 
is a column II code to column I code 93306 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for code 93320 billed for date of service March 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine disposable supplies (A0498) provided on April 10, 
2022. 
 You asked the Plan to pay for the ambulance supplies. You say that these services were medically necessary 
and should be paid. The Plan denied your request. The Plan says they have agreed to pay for the ambulance 
transportation and rhythm tracing services; however, ambulance supplies are not separately billable. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for routine disposable supplies (A0498) provided on April 10, 
2022.