Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency oral evaluation (D0140) provided on October 6, 2021. 
 
You asked the Plan to pay for the dental service. You say that the service should be covered. The Plan denied 
your request. The Plan says 1 emergency oral evaluation is covered every 12 months. The Plan also says that 
the frequency limit has been exceeded. 
 
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 and the service is listed as covered, the 
frequency limit has been exceeded. The record shows that the Plan paid for an emergency oral evaluation that 
you received on March 30, 2021. Therefore, we decided that the Plan does not have to pay for the emergency 
oral evaluation (D0140) provided on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous (IV) iron therapy 510 mg every three days, 
for a total of 52 visits in the next year. 
 
You asked the Plan to pre-approve the 52 visits of IV iron therapy. You say that these services are medically 
necessary. The Plan denied your request. The Plan says you have requested a quantity of services that are not 
medically necessary. The Plan says that only 6 visits per authorization request will be approved as the patient 
needs to be reevaluated.  It is not medically necessary to request one year's worth of treatments at a time. 
 
Medicare rules say that IV iron therapy is covered when medically necessary for the treatment of iron 
deficiency anemia. 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 52 visits of IV 
iron therapy. Our reviewer says that the requested number of IV treatments are not medically necessary. Our 
physician reviewer found no iron panel was provided and the patient's lab levels do not justify the number of 
services requested. 
 
 
 
 
 
 
 
 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 52 visits of IV iron therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve intravenous (IV) iron therapy 510 mg every three days, for a total of 52 
visits in the next year.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from June 22, 
2021, to June 29, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not feel like 
you should have to pay the five days but should only be responsible for three days. 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 $310 
per day, per admission for inpatient hospital care. Your stay totals seven days, making your total copay $2170. 
 
 
 You have been asked to pay a $2170 copay for the inpatient hospital stay. The inpatient hospital stay falls 
within the Inpatient hospital care 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 
the inpatient hospital stay from June 22, 2021, to June 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 13, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services were 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 services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for laboratory services provided on July 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 anesthesia services (99140) provided on August 26, 2021. 
 
You asked the Plan to pay for code 99140. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Code 99140 has a status code of "B" under the Medicare Physicians 
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as 
payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided 
that the Plan does not have to pay for the anesthesia services (99140) provided on August 26, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 gene analysis services. 
 
You asked the Plan to pre-approve F2 gene analysis services. You say that the clinical documentation provided 
supports the need for the requested genetic testing. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for the variant in the F2 gene is 
non-covered except for pregnant patients.  
 
We looked at the file and Medicare rules. The records do not show that the enrollee is pregnant. Based on this 
information, we decided that Medicare rules for coverage of F2 gene analysis services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve F2 gene analysis services.
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 limited field of view  less than one 
whole jaw (D0364) provided November 17, 2021. 
 
You asked the Plan to pay for the limited oral exam and cone beam CT scan. You say that this was an urgent 
procedure to assess an infection. The Plan denied your request. The Plan says you have exceeded the frequency 
limit for the limited oral exam and the CT scan is not a covered dental 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 the limited 
oral exam once per plan year. 
 
We looked the file and Medicare rules. The Plan provided documentation showing that a limited oral exam was previously covered on November 16, 2021. Based on this information, we decided that the Plan's frequency 
limit for coverage of the limited oral exam has been exceeded. Though the Plan offers dental benefits in excess 
of Medicare coverage, the cone beam CT scan is not among those covered services. 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 limited field of view  less than one whole jaw 
(D0364) provided November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on October 25, 2021. 
 
You asked the Plan to pay for the surgical extraction. You say that the tooth extraction should be classified as a 
medical emergency. You also say that your copay should not apply. The Plan denied your request. The Plan 
says there is a 50% coinsurance for extractions received in network. The Plan also says the claim was 
processed correctly. 
 
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 and extraction is listed as covered, there 
is a 50% coinsurance that applies. This is a contractual obligation you agreed to when you enrolled in the 
Plan's dental coverage. Therefore, we decided that the Plan does not have to pay for the surgical extraction 
(D7210) provided on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic evaluation (D0120), and adult prophylaxis 
(D1110) provided by an out-of-network provider on November 1, 2021. 
 
You asked the Plan to pay for a periodic evaluation and adult prophylaxis. You say that you would like the Plan 
to pay for this. The Plan denied your request. The Plan says the benefit limit for these services have already 
been met. 
 
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 a periodic 
evaluation and adult prophylaxis twice a calendar year.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D0120 and D1110 were 
provided on April 27, 2021. Based on this information, we decided that the Plan's rules for coverage of a periodic evaluation and adult prophylaxis have already been met. Therefore, we decided that the Plan does not 
have to pay for a periodic evaluation (D0120), and adult prophylaxis (D1110) provided by an out-of-network 
provider on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implant removal (20680) provided on August 26, 2021. 
 
You asked the Plan to pay for an implant removal. You say that this was requested by the physician. The Plan 
denied your request. The Plan says this is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 20680 
is a column II code to column I code 27447. 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 an implant removal (20680) provided on August 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the allograft services provided on June 22, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says payment is 
bundled into payment for other services. 
 
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 CPT code 20930 is a bundled code. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the allograft services provided on June 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the manual wheelchair purchased from the 
out-of-network (OON) provider on September 22, 2021. 
 
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says the item was rendered by an out of 
network provider that does not participate in the Medicare program. 
 
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, pre-approved care, and for services obtained through the Point of Service (POS) 
benefit. Additionally, the rules state that no provider or supplier shall receive payment for services furnished to 
a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. 
 
The provider in this case is not a network provider with the Plan. The Plan contract states that durable medical 
equipment and supplies are not covered when rendered by an out-of-network provider. Further, the contract 
states that the enrollee will be responsible for the entire cost of the durable medical equipment provided by an 
out-of-network provider. Additionally, this item was purchased from a provider who does not participate in the 
Medicare program. Therefore, we decided that the Plan does not have to issue reimbursement for the manual 
wheelchair purchased from the out-of-network (OON) provider on September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the glycosylated hemoglobin testing provided on October 19, 
2021, billed with code 83036. 
 
You asked the Plan to pay for the glycosylated hemoglobin testing. You say that this testing should be 
approved. The Plan denied your request. The Plan says the testing provided was approved as ordered by a 
network provider. However, the code 83036 cannot be billed with 82985. As such, this one code remained 
denied. 
 
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 83036 
is a column II code to column I code 82985. 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 the glycosylated hemoglobin testing provided on October 19, 
2021, billed with code 83036.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the annual wellness visit provided via telehealth by an out-of-network 
(OON) provider on May 18, 2021. 
 
You asked the Plan to pay for the OON telehealth services. You say that this was medically necessary and 
should be covered. The Plan denied your request. The Plan says that even under a Preferred Provider 
Organization (PPO), only in-network providers can be used for telehealth services. 
 
The Plan must follow Medicare rules. Medicare rules say that health plans may choose to offer additional 
telehealth services that are treated as basic Medicare benefits, and that these must be provided by network 
providers only. However, for the COVID-19 public health emergency (PHE), the limitations on the types of 
providers able to offer telehealth services have been waived. 
 
In this case, though the Plan can only cover "additional telehealth services" from network providers, during the 
PHE, this type of service is not an additional telehealth benefit offered by the Plan. All providers who can bill 
Medicare can be paid for telehealth services, and as this Plan covers Medicare services from OON providers, 
these services cannot be denied due to the limitations imposed for "additional telehealth benefits". Therefore, 
we decided that the Plan has to pay for the annual wellness visit provided via telehealth by an out-of-network 
(OON) provider on May 18, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that SNF care is medically necessary. The Plan 
denied your request. The Plan says you do not meet Medicare criteria for coverage of SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation that you 
require the services on an inpatient basis, only in a skilled nursing facility setting. A lower level of care appears 
appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Molecular ID- UTI panel provided on August 25, 2021. 
 
You asked the Plan to pay for the molecular testing panel. You say that this is medically necessary testing. The 
Plan denied your request. The Plan says the POS code reports on the claim does not match where the lab 
sample was collected. 
 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 molecular testing panel 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 the Molecular ID- UTI panel provided on August 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Outpatient Surgery on May 7, 2021 
 
You asked the Plan to waive the coinsurance for Outpatient Surgery. You say that you were told that your out 
of pocket would be 0. The Plan denied your request. The Plan says the service was provided by an out of 
network provider. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% 
coinsurance for an out-of-network Outpatient Surgery service. The allowed amount of this surgery is 
$6,310.20, resulting in a coinsurance amount of $3,155.10. 
 
You have been asked to pay 50% coinsurance for Outpatient Surgery. Out-of-network Outpatient Surgery falls 
within the Outpatient Surgery 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 coinsurance for Outpatient 
Surgery on May 7, 2021
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on August 26, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that the correct POS code was reported for this 
service. The Plan denied your request. The Plan says the POS reported does not match the location in which the 
sample was collected. 
 
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 Guardant360 testing 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 the Guardant360 testing provided on August 26, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive drug testing provided on May 18, 2021, billed with code 
G0483. 
 
You asked the Plan to pay for the definitive drug testing. You say that this should be paid. The Plan denied 
your request. The Plan says that this claim was denied. 
 
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. The Plan did not provide a rationale to support denial of payment for this 
service, due to missing the time frame. Review of the file shows that there is a signed order from the treating 
provider, and the lab report supports the use of code G0483. Without any obvious defect in the claim or 
records, we find that the denial of payment is not supported. Therefore, we decided that the Plan has to pay for 
the definitive drug testing provided on May 18, 2021, billed with code G0483.  
 
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.