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

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
March 24, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided by an out-of-network provider on March 
24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 29, 2021, by an out-
of-network provider. 
 
You asked the Plan to pay for the lab services. You say that you were not aware of the requirement of obtaining 
prior authorization. The Plan denied your request. The Plan says both the rendering provider and referring 
provider are non-participating providers with 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 laboratory (lab) services provided on 
November 29, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cancer screening and breast examination provided on 
November 12, 2021. 
 
You asked the Plan to pay for a cancer screening and breast examination. You say that the denial was made in 
error. You say that you were told to submit an appeal with notes. The Plan denied your request. The Plan says 
the out-of-network services were not authorized 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a cancer screening and breast examination 
provided on November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the maxillary partial denture (D5225) provided on 
January 25, 2022. 
 
You asked the Plan to pay more for the maxillary partial denture. You say that you had a new set of dentures 
made but were unaware you would owe anything out of pocket. The Plan denied your request. The Plan says 
your calendar year maximum has been reached. 
 
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 Plan offers a $1,500 combined 
allowance for supplemental preventive and comprehensive dental services every year. The contract says that 
after your annual maximum benefit maximum has been met, you are responsible for the full charges of any 
additional dental services. The record shows that you met the annual maximum benefit while processing this 
claim for the January 25, 2022 date of service and your annual maximum benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pay more for the maxillary partial denture (D5225) 
provided on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and 
cone beam computed tomography (CT) capture and interpretation with field of view of both jaws; with or 
without cranium (D0367) provided January 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the limited oral exam and cone beam CT scan. You say that it was not made 
clear to you that your cost share would be so high when receiving services from this provider. The Plan denied 
your request. The Plan says these services have been processed correctly. 
 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 limited 
oral exam with a $0 copayment once per plan year when provided in-network. The Plan further says that for 
services obtained out-of-network, the Plan only pays up to a certain amount. If you choose to see an out-of-
network dentist, you might be billed by that provider for any amount greater than what the Plan pays, even for 
services listed as $0 copayment. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that they have covered 
the full allowed amount for the limited oral exam ($50). You have been asked to pay the difference between the 
allowed amount and the total cost billed by the OON provider ($62). This means you have been asked to pay 
the correct amount based on your contract with the Plan. Though the Plan offers dental benefits in excess of 
Medicare coverage, the cone beam CT scan is not among those covered services. Based on this information, we 
decided that the Plan's rules for coverage of the limited oral exam and cone beam CT scan have not been met. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused 
(D0140) and cone beam computed tomography (CT) capture and interpretation with field of view of both jaws; 
with or without cranium (D0367) provided January 4, 2022, by an out-of-network (OON) provider.  
 
Your complaint about the difference in costs of services at different providers and feeling that the Plans 
documents are not clear enough 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth visit on February 25, 2022. 
 
You asked the Plan to waive the copayment for a telehealth visit. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says the copayment applied 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 $40 
copayment for a telehealth visit.  
 
You have been asked to pay a $40 copayment for a telehealth visit. A telehealth visit falls within the 
Physician/Practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a telehealth visit on February 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse an additional amount for the ambulance service, advanced 
life support, non-emergency transport (A0426) provided on October 18, 2021. 
 
You asked the Plan to reimburse an additional amount for the ambulance service. You say that you were 
advised you would likely need to file for reimbursement. The Plan denied your request. The Plan says the claim 
processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for Ambulance services.  
 
You have been asked to pay a $225 copayment for the ambulance service. The ambulance service falls within 
the Ambulance 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 reimburse an additional amount for 
the ambulance service, advanced life support, non-emergency transport (A0426) provided on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) provided on October 18, 2021 by a 
non-participating provider. 
 
You asked the Plan to pay for the hearing aids. You say that when you talked with a Plan representative, you 
were advised that the provider you went to could be used. You also say that you would like to receive the $500 
reimbursement. The Plan denied your request. The Plan says the treating provider is non-participating with the 
Plan, and the provider is not part of the Plan's vendor network. The Plan also says that hearing aids ordered 
through providers other than the Plan's approved hearing aid vendor are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are provided by the Plan's hearing aid vendor.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5298) provided on October 18, 2021 by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mandibular partial denture (code D5214).  
 
You asked the Plan to pay for the partial denture. You say that the denture improves your appearance and 
makes you feel very comfortable. The Plan denied your request. The Plan says this service is not covered by 
the Plan's 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 pay for 
mandibular partial denture (code D5214) provided on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for the periodic oral evaluation (D0120) 
provided on February 15, 2022, the comprehensive oral evaluation (D0150), panoramic radiographic image 
(D0330), and prophylaxis (D1110) provided on February 16, 2022, the resin-based composite - one surface 
(D2391), resin-based composite - two surfaces (D2392) provided on February 22, 2022, and the resin-based 
composite - one surface (D2391) provided on March 15, 2022. 
 
You asked the Plan to pay the full amount for the periodic oral evaluation, comprehensive oral evaluation, 
radiographic image, prophylaxis, and resin-based composites. The Plan denied your request. The Plan says 
these services are covered, and the Plan has already paid the full allowed amount. Since these services were 
provided out-of-network you are responsible for the remaining balance. 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. 
 
The Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are covered 
under this benefit, but when provided out-of-network the enrollee is responsible for the remaining balance after 
the allowed amount is paid by the Plan. Therefore, we decided that the Plan does not have to pay the full 
amount for the periodic oral evaluation (D0120) provided on February 15, 2022, the comprehensive oral 
evaluation (D0150), panoramic radiographic image (D0330), and prophylaxis (D1110) provided on February 
16, 2022, the resin-based composite - one surface (D2391), resin-based composite - two surfaces (D2392) 
provided on February 22, 2022, and the resin-based composite - one surface (D2391) provided on March 15, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires inpatient acute rehabilitation to 
facilitate increased dependence and return home and to her community with improved quality of life. The Plan 
denied your request. The Plan says that based on Medicare guidelines, the requested IRF services do not meet 
the requirements for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that Parkinson's disease is an IRF compliant diagnosis. Clinical documentation shows that enrollee 
requires complex medical management and close supervision in an inpatient setting. Evaluating therapists and 
provider state that the enrollee would benefit from multi-disciplinary and intense rehabilitation. Neurology 
states in clinical documentation, along with rehabilitation physician, that the enrollee will make significant 
functional gains in an IRF, and thus meets criteria. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and 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 pool pass purchased on November 27, 2021. 
 
You asked the Plan to pay for the pool pass. You say that you feel that because your regular gym is closed and 
you are using your pass frequently to swim at a local high school, this should be covered. The Plan denied your 
request. The Plan says a pool pass is not covered under the Wellness Allowance Benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only for memberships in a qualified health club or fitness facility. 
 
The Plans rules for coverage of gym benefits have not been met because this pass was purchased through a 
community school and not a qualified health club or fitness facility. Therefore, we decided that the Plan does 
not have to pay for the pool pass purchased on November 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total hip arthroplasty services. 
 
You asked the Plan to pre-approve total hip arthroplasty services. You say that the records provided support the 
need for hip arthroplasty services. The Plan denied your request. The Plan says the requested services are not 
medically necessary because the records show the enrollee has not had adequate attempts at conservative 
treatment, nor an explanation for the reason you have not tried things such as physical therapy and steroid joint 
injection. 
 
The Plan follows Medicare rules. Medicare rules say that total hip replacement is covered for certain clinical 
indications.  
 
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 total hip arthroplasty services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was 
being treated for unilateral primary osteoarthritis of the left hip. She presented with pain in the left hip. There is 
a constant ache, and it bothers her with walking, standing, and activities of daily living. She is failing 
conservative treatment at home. The exam reveals discomfort in her inguinal area with internal and external 
rotation and hip flexion. Strength is 5/5 and X-rays show 20-30 degrees of mobility with flexion and extension 
at the sacrum. However, detailed documentation is not evident regarding trial and failure of recent, reasonable, 
and comprehensive less invasive conservative care measures. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
Therefore, the requested total hip arthroplasty, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of total hip arthroplasty services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve total hip arthroplasty services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient procedure rendered on May 7, 2021 to May 24, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 15271 is not supported.

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, the CPT Code Manual definition of code 15271 is application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area.

We find that CPT code 15271 is not supported in the medical record. Specifically, the low-cost skin substitute was not billed with the required product code. 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 the outpatient procedure rendered on May 7, 2021 to May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 10, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 January 10, 2022 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for electroconvulsive therapy (00104) provided on 
September 24, 2021.  You asked the Plan to pay for anesthesia for electroconvulsive therapy (00104). You say that an approved 
authorization exists, and you are dependent on the facility or surgeon to obtain any necessary referrals or 
authorizations. You say that the anesthesia claim should be reprocessed based on the attached anesthesia 
record. The Plan denied your request. The Plan says the claim does not include the appropriate primary or first-
listed diagnosis. 
 
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, the CPT Code Manual definition of code 00104 is anesthesia for electroconvulsive therapy. 
 
We find that CPT code 00104 is not supported in the medical record. Specifically, the appropriate diagnosis 
code was not billed as the primary diagnosis code on the claim. Based on this information, we decided that 
Medicare rules for coverage of anesthesia for electroconvulsive therapy (00104) have not been met. Therefore, 
we decided that the Plan does not have to pay for anesthesia for electroconvulsive therapy (00104) provided on 
September 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic panel testing provided on October 8, 2021. 
 
You asked the Plan to pay for genetic testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because a panel constitutes 
a single procedural service so one procedure code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that if a lab procedure produces multiple reportable 
test results, only a single code shall be reported for the procedure.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
genetic panel testing provided on October 8, 2021.