Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on August 3, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy. You say that you were unaware an authorization was needed 
for mental health services. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided on August 3, 2021, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on October 12, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that while you have had two visits in 2021, this one was done on an emergency basis. You also say that you would like an exception to be made and you would like this visit considered as an emergency visit outside of the two routine visits you are allowed per year and this charge be covered. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 the problem focused limited oral evaluation (D0140) provided on October 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Boost nutritional supplements (E1399).
You asked the Plan to pre-approve Boost nutritional supplements. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve Boost nutritional supplements (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinalysis provided on September 30, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the urinalysis. You say that the service was medically necessary. The Plan denied 
your request. The Plan says no prior authorization was 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the urinalysis provided on September 30, 2021, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent observation care (99226) provided on October 8, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for subsequent observation care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.
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 subsequent observation care (99226) provided on October 8, 2021, 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 October 28, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that you saw this provider in the past and never had to get a referral from your primary care physician. The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and there was no referral from the enrollee's primary care physician. Also, the services 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 October 28, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the services provided on April 16, 2019.
You asked the Plan to pay for the services. You say that fadfsa The Plan denied your request. The Plan says that this claim line is disallowed because a Present on Admission indicator is not valid for this Type of Bill.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, it is not appropriate to apply POA rules to ASC claims. Additionally, the documentation does not show that the claim in question includes POA indicators. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services provided on April 16, 2019.
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 computed tomography guidance for placement of radiation fields (7701) provided March 31, 2021 to April 2, 2021.
You asked the Plan to pay for the diagnostic service. You say that these procedures were for the guidance of her radiation therapy treatment and nothing to do with the planning. The Plan denied your request. The Plan
says CT guidance for radiation therapy fields will not be separately billed during the duration of the IMRT treatment when code 77301 is billed.
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 77014 is a column II code to column I code 77301. The records show that this provider also billed and was paid for CPT code 77301 for date of service March 1, 2021. 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 computed tomography guidance for placement of radiation fields (7701) provided March 31, 2021 to April 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided
on October 14, 2021.
You asked the Plan to pay for the topical application of fluoride varnish. You say that the dental practice
charged you $36 for the prophylaxis and then charged the Plan, and you want your money refunded. You also
say that you paid $61 and should have only been charged $25 for the fluoride. The Plan denied your request.
The Plan says this service is not a covered expense under your dental plan. The Plan also says that you did not
contact the Plan prior to this date of service to verify benefits and provider eligibility.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's 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 the
topical application of fluoride varnish (D1206) provided on October 14, 2021.
Your complaint about your disappointment in the Plan for not taking fraud seriously is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on October 21, 
2021 and billed under code 70450. 
 
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 e a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit 
exists between 70496 and 70450. This PTP edit has a modifier indicator of 1, which indicates modifiers 
associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP 
code edit 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and when required the appropriate modifier.  
In this case, this claim cannot be paid as billed due to the omission of the required modifier. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for medical services provided to the enrollee on October 21, 2021 
and billed under code 70450.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140),
detailed and extensive oral evaluation (D0160), maxillary interim partial denture (D5820), complete series of
intraoral x-rays (D0210), and first intraoral periapical x-ray (D0220) provided from June 23, 2020, to July 9,
2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the problem focused limited oral evaluation, detailed and extensive oral
evaluation, maxillary interim partial denture, complete series of intraoral x-rays, and first intraoral periapical xray.
You say that these services were rendered due to an emergency, and you did not have time to check for innetwork
dentists. The Plan denied your request. The Plan says the problem focused limited oral evaluation,
detailed and extensive oral evaluation, and maxillary interim partial denture are not covered services. The Plan
also says that services performed by an OON provider are not covered because your healthcare plan does not
have OON benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the problem focused limited oral
evaluation, detailed and extensive oral evaluation, and maxillary interim partial denture are not among those
covered under this benefit. The contract also says that you are responsible for 100% of the cost for dental
services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the
problem focused limited oral evaluation (D0140), detailed and extensive oral evaluation (D0160), maxillary
interim partial denture (D5820), complete series of intraoral x-rays (D0210), and first intraoral periapical x-ray
(D0220) provided from June 23, 2020, to July 9, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for recement or re-bond of an implant/abutment supported crown (D6092) provided on October 27, 2021.
You asked the Plan to pay for the dental service. You say that this service was necessary, and you understood you had a $1,000 annual limit for any dental service with any provider. The Plan denied your request. The Plan says this service is not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 recement or re-bond of an implant/abutment supported crown (D6092) provided on October 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0481) provided on October 20, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says these services were not authorized by the 
Plan. 
 
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 drug testing services (G0481) provided on 
October 20, 2021 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 limited oral evaluation (D0140), and anesthesia (D9215) 
provided by a participating provider on October 26, 2021. 
 
You asked the Plan to pay for a limited oral evaluation and anesthesia. You say that you would like the Plan to 
pay for this. The Plan denied your request. The Plan says the frequency for D0140 has already been exhausted. 
The Plan says that D9215 is not 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. The Plan covers one limited 
oral evaluation were calendar year. Anesthesia services are not a covered benefit.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a limited oral evaluation have already been met, and anesthesia is not a covered benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), and anesthesia 
(D9215) provided by a participating provider on October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204) and an x-ray exam of the shoulder (73030) provided on July 6, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit and an x-ray exam of the shoulder. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the services provided require prior authorization for non-contracted providers and no authorization has been 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 an office visit (99204) and an x-ray exam of the shoulder (73030) provided on July 6, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of speech provided on March 13, 2021, by an
out-of-network (OON) provider.
You asked the Plan to pay for the treatment of speech. You say that the services, with the same procedure code,
for this enrollee were paid for from May 6, 2021, to September 11, 2021. You would like this claim paid. The
Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The record shows the referring provider became a network provider on April 1, 2021. Therefore, we decided that the Plan does not have to pay for the treatment of speech provided on March 13, 2021, 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 domiciliary home visit (99336) provided on October 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary home visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the services were not urgent, emergent or approved in advance.
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 domiciliary home visit (99336) provided on
October 1, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to return to being independent. The 
Plan denied your request. The Plan says you do not have acutely complex medical diagnosis and do not require 
supervision by a rehabilitation physician. You do not meet all the required Medicare criteria for admission to 
an IRF. 
 
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 that you are medically stable and do not need physical medicine and 
rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbation of chronic medical conditions. At the current level of function, you do not need 
intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach to daily therapy in an IRF. You need routine physical and occupation therapy. Your 
therapy needs can be addressed in a skilled nursing facility. An IRF admission is not medically necessary based 
on lack of medical complexity and lack of acute rehab nursing needs. The documentation does not support the 
necessity for admission to an IRF. Your rehabilitation needs can be met safely at a lower intensity and alternate 
setting. 
 
 
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 inpatient rehabilitation facility (IRF) admission and services.