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

 
We decided that the Plan does not have to pay for an office visit provided on June 7, 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 June 7, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 8, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are requesting claim be reprocessed and 
paid because services were medically necessary. The Plan denied your request. The Plan says an authorization 
was not obtained prior to services rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on August 8, 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 chiropractic services provided on August 3, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says authorization was not obtained prior to services being rendered. 
 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 chiropractic services provided on August 3, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tissue pathology exam provided on July 19, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the tissue pathology exam. You say that the facility does not see the patient and 
cannot facilitate authorization. The Plan denied your request. The Plan says a referral/authorization was not 
obtained prior to services being rendered. 
 
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 tissue pathology exam provided on July 19, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on July 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that the services were medically necessary. 
The Plan denied your request. The Plan says authorization was not obtained prior to services being rendered. 
 
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 wound care supplies provided on July 1, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous (IV) infusions for hydration. 
 
You asked the Plan to pre-approve intravenous (IV) infusions for hydration. You say that the patient has not 
been eating for a week, is weak, cannot ingest food and cannot swallow. The Plan denied your request. The 
Plan says the requested intravenous (IV) infusions for hydration purposes does not meet the Medicare LCD 
coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 intravenous (IV) infusions for 
hydration. Our reviewer says that intravenous (IV) infusions for hydration is not medically necessary. Our 
physician reviewer found that the enrollee is an 85-year-old female with diabetes, kidney disease, 
atherosclerosis, chronic obstructive pulmonary disease (COPD), and arthritis was recommended IV fluids with 
multivitamins due to poor oral intake for one week due to dysphagia. However, it was not clear from the 
provided records as to why a feeding tube was not considered for this enrollee or how basic macronutrient 
nutrition was planning on being provided for this enrollee, which is preferred over simply fluids and vitamins 
alone. There was insufficient support for this request, and this request for IV hydration with multivitamins does 
not meet the Medicare LCD coverage criteria based on the provided documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intravenous (IV) infusions for hydration have not been met. Therefore, we 
decided that the Plan does not have to pre-approve intravenous (IV) infusions for hydration.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 28, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you disagree with the denial for services 
rendered on date of service October 28, 2021. The Plan denied your request. The Plan says an authorization 
was not obtained prior to services rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on October 28, 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 localized delivery of antimicrobial agents (D4381), drugs 
for home use (D9630), gingival irrigation (D4921) and periodontal scaling and root planing (D4341, D4342) 
provided on June 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says that the localized delivery of antimicrobial agents (D4381), drugs 
for home use (D9630), and gingival irrigation (D4921) are not covered by your supplemental dental benefits. 
The Plan also says that your benefit for periodontal scaling and root planing has already been exhausted. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the localized delivery of antimicrobial 
agents (D4381), drugs for home use (D9630), and gingival irrigation (D4921) are not among those covered 
under this benefit. The record shows your benefit for periodontal scaling and root planing was exhausted on 
date of service January 14, 2022. Therefore, we decided that the Plan does not have to pay for the localized 
delivery of antimicrobial agents (D4381), drugs for home use (D9630), gingival irrigation (D4921) and 
periodontal scaling and root planing (D4341, D4342) provided on June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and a tooth extraction by an oral surgeon. 
 
You asked the Plan to pre-approve a consultation and a tooth extraction by an oral surgeon. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not 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 states covered dental 
services must be performed by a participating general dentist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a consultation and a tooth extraction by an oral surgeon have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a consultation and a tooth extraction by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D2950, D6245 and the second D6740) 
on July 20, 2022. 
 
You asked the Plan to pay for the dental services (D2950, D6245 and the second D6740). You say that you 
would like to request reconsideration of the denied claim. The Plan denied your request. The Plan says your 
benefit for the requested services has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 20, 2022. Therefore, we decided that the Plan does not have to pay for the dental services (D2950, D6245 and the second D6740) on 
July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete intraoral x-ray series (D0210), a panoramic x-ray 
(D0330), periodontal scaling and root planing in the upper left quadrant (D4342), oral hygiene instructions 
(D1330), gingival irrigation (D4921), and unspecified periodontal procedures (D4999) provided on July 25, 
2022, and periodontal scaling and root planing in the upper and lower right quadrants (D4342), an adjunctive 
pre-diagnostic test (D0431), gingival irrigation (D4921), and unspecified periodontal procedures (D4999) 
provided on August 1, 2022. 
 
 You asked the Plan to pay for the dental services. You say that your dentist told you that more work was 
needed, and the services would be covered. The Plan denied your request. The Plan says your benefit for a 
complete intraoral x-ray series, a panoramic x-ray, and periodontal scaling and root planing had already been 
exhausted. The Plan also says that oral hygiene instructions, gingival irrigation, an adjunctive pre-diagnostic 
test, and unspecified periodontal procedures are not covered by your supplemental 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, oral hygiene instructions, gingival 
irrigation, an adjunctive pre-diagnostic test, and unspecified periodontal procedures are not among those 
covered under this benefit. The record shows your benefit for a complete intraoral x-ray series, a panoramic x-
ray, and periodontal scaling and root planing was exhausted on date of service June 19, 2020. Therefore, we 
decided that the Plan does not have to pay for a complete intraoral x-ray series (D0210), a panoramic x-ray 
(D0330), periodontal scaling and root planing in the upper left quadrant (D4342), oral hygiene instructions 
(D1330), gingival irrigation (D4921), and unspecified periodontal procedures (D4999) provided on July 25, 
2022, and periodontal scaling and root planing in the upper and lower right quadrants (D4342), an adjunctive 
pre-diagnostic test (D0431), gingival irrigation (D4921), and unspecified periodontal procedures (D4999) 
provided on August 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the low-level laser treatment (LLLT) (0552T) provided from 
March 1, 2022, to April 21, 2022. 
 
You asked the Plan to pay for the laser treatment after March 1, 2022. You say that this is the only treatment 
that has alleviated your pain. The Plan denied your request. The Plan says the services were not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laser treatment have been met. Specifically, there are no medical records to support that the services were medically necessary or coverable. 
Therefore, we decided that the Plan does not have to pay for the low-level laser treatment (LLLT) (0552T) 
provided from March 1, 2022, to April 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 additional home health skilled nursing visits. 
 You asked the Plan to pre-approve home health skilled nursing visits. You say that additional home health 
services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the request is 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 home health skilled nursing visits. Our 
reviewer says that the requested services are not a medical necessity for the enrollee. Our physician reviewer 
found that the enrollee is medically stable and has no medical needs that would require the skilled services of a 
nurse. The enrollee does not require active management of medical issues, administration of intravenous 
antibiotics, percutaneous endoscopic gastrostomy (PEG) tube or colostomy management or wound care. The 
enrollee is forgetful and requires supervision and assistance due to her dementia, but this does not require the 
skilled services of a nurse. The enrollee's caregivers have been educated in terms of appropriate care and 
supervision. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 3 additional home health skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the joystick armor (K0108), power seat elevation 
system (E2300), and expandable controller (E2377, E2311, E2313). 
 
You asked the Plan to pre-approve the requested power wheelchair accessories. You say that this equipment is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the criteria for coverage have 
not been met for the requested equipment. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is necessary when the 
enrollee is unable to control the approved power options through their own switches. The rules say that for 
equipment to be covered, it must primarily serve a medical purpose.  The rules say that a power seat elevation 
feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in 
nature 
 
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 requested power wheelchair 
accessories. Our reviewer says that the requested expandable controller is not medically reasonable and 
necessary. Our physician reviewer found that the enrollee has lost strength in her left hand but has good 
function remaining in right hand with good range of motion. In this case, the enrollee has sufficient strength 
and range of motion to utilize standard switches and does not require the expandable controller. In addition, the 
power seat elevation system and joystick armor both are non-covered as they are not primarily medical in 
nature. 
 
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 requested power wheelchair accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the joystick armor (K0108), power seat elevation system 
(E2300), and expandable controller (E2377, E2311, E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D5750, D5226, D0220, and D2335) on 
June 7, 2022. 
 
You asked the Plan to pay for the dental services (D5750, D5226, D0220, D0230, D2330 and D2335). You say 
that you would like to request reconsideration for payment. The Plan denied your request. The Plan says the 
dental services (D5750, D5226, D0220 and D0220) are not covered services. The dental service (D2335) is 
only covered once per calendar year. 
 
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 the dental 
services (D5750, D5226, D0220, and D2335) on June 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic lab testing provided on June 2, 2022, billed with 
10 units of code 87150. 
 
You asked the Plan to pay for the testing as billed. You say that the claim should be paid in full. The Plan 
denied your request. The Plan says all codes were paid except for 87150 which 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 87150 is Culture, typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed.  
We find that CPT code 87150 is not supported in the medical record. Specifically, there is not sufficient detail 
in the lab report to support that cultures with DNA testing were performed. It cannot be confirmed what 87150 
corresponds to on the report. Based on this information, we decided that Medicare rules for coverage of the 
testing as billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic lab 
testing provided on June 2, 2022, billed with 10 units of code 87150.