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

 
We decided that the Plan does not have to pre-approve dialysis to be provided while in the Republic of Korea. 
 
You asked the Plan to pre-approve dialysis. You say that for a patient with end-stage renal disease, continuing 
dialysis while travelling is both reasonable and necessary to live. The Plan denied your request. The Plan says 
the denial of authorization for this service is correct, because this provider would be out-of-network with the 
Plan and the enrollee is being treated by an in-network provider. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside of the 
United States and its territories are excluded from coverage, except in limited specified circumstances. The 
Plan has a worldwide coverage benefit that goes beyond Medicares coverage. For that reason, the Plans rules 
apply to this request. The Plan covers worldwide emergency and urgent care which includes a visit to the 
emergency room or urgent care facility for symptoms that require immediate medical attention. 
 
We looked at the file and Medicare rules. This request does not fall within any of the situations in which 
Medicare would cover out-of-country services. Additionally, this request does not meet the Plans criteria for 
coverage of worldwide services because the need for dialysis is foreseeable prior to travelling, meaning that the 
enrollees care needs are not emergent or urgent at this time. Please contact the Plan for more information 
about the worldwide coverage that the enrollee may receive while travelling outside of the United States. Based 
on this information, we decided that Medicare rules for coverage of dialysis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve dialysis to be provided while in the Republic of Korea.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient clinic visit provided to the enrollee from March 
4, 2022, to March 18, 2022. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says insufficient medical records were provided, and a required evaluation and management 
(E&M) code was not included on the claim. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and provide medical records to support the services 
billed. The case file shows the Plan made several attempts to have you submit both a corrected claim and 
additional medical records. Those requests were not responded to. Medicare billing criteria are not met.  
Therefore, we decided that the Plan does not have to pay for an outpatient clinic visit provided to the enrollee 
from March 4, 2022, to March 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on March 2, 2022. 
 
You asked the Plan to pay for the services provided. You say that routine drug testing is necessary to monitor 
the use of prescriptions. The Plan denied your request. The Plan says the service cannot be separately 
reimbursed. 
 
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. We find that the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab testing services provided on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam and services (codes 92083, 
92133, and 99214) provided on May 10, 2022. 
 
You asked the Plan to waive the copayment for the eye exam and services. You say that you were supposed to 
receive an annual eye exam with no copayment. The Plan denied your request. The Plan says the copayment 
amount you are being charged is correct. 
 
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 $35 
copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye under the Vision care 
benefit category.  
 
 
 
 You have been asked to pay a $35 copayment for the eye exam and services. The eye exam and services 
provided fall within the Vision care benefit category. The record shows that you received a diagnostic eye 
exam on this date of service. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the eye exam and services 
(codes 92083, 92133, and 99214) provided on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0274, D0120, D1110) provided on May 
18, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and covers 50% of the allowed amounts. 
 
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 only covered 50% 
when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for 
the rest of the dental services (D0274, D0120, D1110) provided on May 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transportation (A0429) and 
ground mileage (A0425) provided on March 15, 2021. 
 
You asked the Plan to pay for the emergency ambulance transportation and ground mileage. You say that you 
would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says an original 
claim submission must be filed to the appropriate Medicare claims processing contractor no later than 12 
months, or 1 calendar year, after the date the services were furnished. The Plan also says that this claim was 
untimely. 
 
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 the emergency ambulance transportation and ground mileage was not filed 
until May 17, 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 emergency ambulance 
transportation (A0429) and ground mileage (A0425) provided on March 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power wheelchair received on January 3, 2022. 
 
You asked the Plan to pay for the wheelchair. You say that this should be paid for. The Plan denied your 
request. The Plan says the requirements are not met due to a lack of documentation that an on-site home 
evaluation was completed to ensure the environment can accommodate this wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that the 
wheelchair at issue in this case is not medically reasonable or necessary. Our physician reviewer found that 
based on the medical records provided there is no documentation that your mobility deficit cannot be helped by 
the use of a walker, cane or manual wheelchair. The records specifically report that you are able to self-propel 
with a manual wheelchair. There is no documentation that you are able to safely operate this power wheelchair. The provided medical records do not report that an on-site home evaluation was completed to ensure the 
environment can accommodate this wheelchair. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pay for a power wheelchair received on January 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 9, 2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D5110, D5120, D6057, D7953) 
 
You asked the Plan to pre-approve the dental 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 do 
not fall within your dental 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. 
 
 
  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 
dental services (D5110, D5120, D6057, D7953)
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 14, 2022, to 
January 21, 2022. You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an 
appropriate claim was not submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The documentation does not show the claim was billed with the correct type 
of bill. Based on this information, we decided that Medicare rules for coverage of the services provided have 
not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided 
from January 14, 2022, to January 21, 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 you are able and willing to participate in an intensive 
rehabilitation program in hopes of regaining lost function and improving the quality of your life. The Plan 
denied your request. The Plan says admission to IRF was denied as not meeting criteria, is not medically 
necessary, and a lower level of care might be appropriate. Skilled nursing facility level of care was offered. 
 
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 you are at a level of function which does not require intensive therapy, and you 
cannot reasonably benefit from the intensive therapy. You are able to improve walking with repetitive exercise. 
There are no complex nursing or rehabilitation needs. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 23, 2022, by an out-of-
network (OON) provider. 
 
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 the services were provided out-of-network and were not approved 
in advanced. 
 
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 laboratory services provided on May 23, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on May 12, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 02/03/2022. Therefore, 
we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hernia repair (49505) provided on May 3, 2022, by 
the opt-out provider. 
 
You asked the Plan to pay for the surgical service. You say that the surgery was performed by an out-of-
network doctor. You say that you do not understand how this cannot be covered. The Plan denied your request. 
The Plan says payment cannot be made to a provider that has opt-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The service at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the initial 
hernia repair (49505) provided on May 3, 2022, by the opt-out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services on January 18, 2022, and January 31, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services are not covered 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
services on January 18, 2022, and January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown (D2750) 
 
You asked the Plan to pre-approve the dental crown. 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 you do 
not qualify for them, the c-rays show you do not have enough tooth to support the crowns. 
 
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 a 
dental crown (D2750)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and 
efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment visits provided on November 
1, 2021 to November 29, 2021, by an OON provider. 
 
You asked the Plan to pay for medication assisted treatment visits. You say that you are appealing the denial of 
the services provided. 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 medication assisted treatment visits provided on 
November 1, 2021 to November 29, 2021, by an OON provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the GTC Hematology Profile provided on November 29, 2021. 
 
You asked the Plan to pay for the GTC Hematology Profile. You say that you would like this claim reprocessed 
and approved for payment as this test was approved by the MolDX program and was medically necessary. The 
Plan denied your request. The Plan says that there are Medicare coverage determinations which indicate that 
panels that include FANCC and BLM genes are 
noncovered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Though this panel does include genes that another coverage rule 
indicates are noncovered, we find there is no basis to overrule the specific coverage decision made by the 
MolDX contractor for this particular test. Based on this information, we decided that Medicare rules for 
coverage of the GTC Hematology Profile have been met. Therefore, we decided that the Plan has to pay for the 
GTC Hematology Profile provided on November 29, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on December 22, 
2021. 
 
You asked the Plan to pay for the services provided. You say that the documentation supports medical 
necessity. The Plan denied your request. The Plan says the r ules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. We find that the claim reported G0463, an evaluation and management 
service, without an appropriate modifier. We also find that CPT code G1004 is not paid by Medicare when 
submitted on an outpatient claim. Based on this information, we decided that Medicare rules for coverage of 
the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
outpatient hospital services provided on December 22, 2021.