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

 
We decided that the Plan does not have to pay for lab services (81404, 81479) provided April 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81404, 81479) provided April 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
total shoulder reverse arthroplasty and will need inpatient admission after surgery. The Plan denied your 
request. The Plan says there is no documentation provided to support the expectation the enrollee will require a 
greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is approved for a total shoulder reverse arthroplasty. The 
record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 
or more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 15 home health skilled nursing visits. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the documentation does not support 
that the enrollee requires additional skilled nursing services beyond what has been approved. He does not 
require additional skilled nursing services to effectively provide treatment, care, and/or services in order to 
improve his condition, perform a maintenance program to maintain his condition and/or prevent deterioration. 
He has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 
There is no indication of recent evaluation by a physician provider that would support active management of 
the chronic wound. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 15 home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit provided on January 3, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. You say that the doctor must see all patients in the nursing 
home that need care. The Plan denied your request. The Plan says the services were provided out-of-network 
and 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 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 outpatient visit provided on January 3, 2022 by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a back brace provided on February 7, 
2022. 
 
You asked the Plan to reduce the coinsurance for the back brace. You say that the amount charged is too much. 
The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 20% 
coinsurance for prosthetic devices and medical supplies, including braces.  
 
You have been asked to pay $152.07, which is 20% of the allowed amount for the back brace ($760.38 allowed 
amount x 20% coinsurance = $152.07). The back brace falls within the Prosthetic Devices and Related 
Supplies 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 coinsurance for a back brace provided on 
February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on February 8, 2022. 
 
You asked the Plan to pay for the dental service. You say that you have been seeing this dentist for at least a 
year and a half now. You say that up until now you have not had issues with your coverage. You also say that 
the service should be covered. The Plan denied your request. The Plan says the provider in this case is not your 
assigned dental provider. The Plan also says that for services to be covered, you must receive dental care from 
your assigned dentist. 
 
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, dental services received by a dentist 
other than your assigned Dental Plan dentist are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on February 8, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health services provided from July 1, 2021, to July 12, 2021, by an OON provider.

You asked the Plan to pay for the behavioral health services. You say that the enrollee self-referred and you were unaware the enrollee switched insurances. The Plan denied your request. The Plan says the rendering provider is an OON provider and there are multiple in-network providers that provide the same quality of service. Also, the service rendered was not urgent and 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 the behavioral health services provided from July 1, 2021, to July 12, 2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) 
provider on November 11, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) provider on  
November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve dental services (D6011, D6056, D6110). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the x-rays do not show that this is medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the services 
when the services are medically necessary and reasonable. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found a review of the 
documentation indicates the presence of implant bodies in the maxillary arch and an atrophic maxillary alveolar 
ridge. The placement of an implant supported complete maxillary denture is medically reasonable and 
necessary to provide retention and stability for adequate masticatory function. The documentation provided 
meets the criteria for coverage of medically reasonable and necessary for D6011, D6056 and D6110. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-
approve dental services (D6011, D6056, D6110).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81241, 81240). 
 
You asked the Plan to pre-approve the genetic testing. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a non-coverage policy for genetic testing 
for thrombophilia testing for the Factor V Leiden (FVL) variant in F5 gene, the 20210G>(G20210A) variant in 
the F2 gene, and the MTHFR gene which encodes the 5, 10-methylenetetrahydrofolate reductase enzyme. 
Genetic testing for these genes for all risk factors, signs, symptoms, diseases, or conditions, including 
cardiovascular risk assessment, are non-covered except for pregnant patients. 
 
We looked at the file and Medicare rules. This type of genetic testing is non-covered except for pregnant 
patients. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not 
been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (81241, 81240).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (G0480, 80307, 82542, 84228) 
rendered by the out-of-network (OON) provider on January 25, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider 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 laboratory services (G0480, 80307, 82542, 84228) rendered by the out-of-
network (OON) provider on January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the provider's prosthetic knee component code 
L5845 (knee-shin system stance flexion feature). 
 
You asked the Plan to pre-approve prosthetic component. You say that you are in need of this to safely 
ambulate. The Plan denied your request. The Plan says the denial of authorization for this component is correct, 
because the use of code L5845 is not appropriate. 
 
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 prosthetic component. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found A level 3 ambulator has the ability or potential for ambulation with variable cadence. 
Typical of the community ambulator who has the ability to traverse most environmental barriers and may have 
vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. In 
this case, the documentation indicates that you are a K3 ambulator and have been authorized to have a 
complete prosthesis - including a knee-shin system - that is appropriate for you. The requested brand-name 
equipment appears to be a duplication in services and is not 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 prosthetic component have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the provider's prosthetic knee component code L5845 (knee-shin system 
stance flexion feature).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the panoramic x-ray (D0330) provided on March 10, 2022. 
 
You asked the Plan to pay for the dental service. You say that your last panoramic x-ray was in 2017. You say 
that you had to find a new dentist due to your previous dentist's network status. You say that the dentist insisted 
on doing x-rays. You also say that a plan representative advised your dental office that the x-ray would be 
covered. The Plan denied your request. The Plan says that panoramic x-ray is covered once every 36 months. 
The Plan also says that the frequency limit has been exceeded. 
 
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. Specifically, the Plan did not provide a copy of the applicable Evidence of 
Coverage for this case. Without this information we cannot determine that the Plan's coverage rules support the 
denial of payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and 
benefits. Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we 
decided that the Plan has to pay for the panoramic x-ray (D0330) provided on March 10, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and bitewing x-
rays (D0274) provided on August 4, 2020. 
 
You asked the Plan to pay for the dental services. You say that you have not exceeded the limit of prophylaxis. 
You say that you can have 2 cleanings per year. You say that you have not had any. You also say that this 
cleaning should be covered. The Plan denied your request. The Plan says the frequency limits for the 
comprehensive oral evaluation and bitewing x-rays have been exceeded. 
 
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 and the services are listed as covered, 
the frequency limits have been exceeded. Comprehensive oral evaluation is covered once every 3 plan years. 
Bitewing x-rays are covered once per plan year. The record shows that the Plan paid for a comprehensive oral 
evaluation and bitewing x-rays that you received on February 18, 2020. Therefore, we decided that the Plan 
does not have to pay for the comprehensive oral evaluation (D0150) and bitewing x-rays (D0274) provided on 
August 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound debridement services (11042) 
provided on January 4, 2022. 
 
You asked the Plan to waive the copayment for the wound debridement services. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-
sharing applied correctly based on the services provided. 
 
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 $250 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $250 copayment for wound debridement services. Wound debridement services 
fall within the Outpatient hospital 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 waive the copayment 
for wound debridement services (11042) provided on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on  
October 28, 2021. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says the services were not ordered or performed 
by an in-network Plan provider. An authorization was not 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 
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 a domiciliary or rest home visit provided on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010), custom fabricated 
abutments (D6057), and abutment supported crowns (D6058), provided by a participating provider. 
 
You asked the Plan to pre-approve endosteal implants, custom fabricated abutments, and abutment supported 
crowns. You say that you would like the Plan to approve these services. The Plan denied your request. The 
Plan says the requested services are not covered. 
 
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 
endosteal implants (D6010), custom fabricated abutments (D6057), and abutment supported crowns (D6058), 
provided by a participating provider.