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

We decided that the Plan does not have to pay for the gene panel testing provided to the enrollee on May 27, 2022.

You asked the Plan to pay for the testing services. You say that the information validates medical necessity of the testing. The Plan denied your request. The Plan says that the claim was billed with an inconsistent date of service.

The Plan must follow Medicare rules. Medicare rules say that the general rule for the date of service (DOS) policy for either a clinical laboratory test or the technical component of physician pathology service is to bill the date the specimen was collected as the date of service. Maximus overturned the Plan's denial. The Plan requested a reopening stating that the specimen was obtained in a laboratory and has the incorrect date of service on the claim form. The claim shows a Place of Service of an independent laboratory. The rules state that the date of service submitted on the claim form must be the date the specimen was collected if the specimen was collected in a laboratory. The specimen was collected on July 21, 2021, but the date of service on the claim form was May 27, 2022.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the gene panel testing provided to the enrollee on May 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing - one to three teeth per 
quadrant (D4342) and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) 
provided on October 18, 2022, and October 20, 2022. 
 
You asked the Plan to pay for dental services. You say that you do not understand why the requested services 
were not covered, because you were told you only had a $25 copayment. The Plan denied your request. The 
Plan says these services are not covered under your Plan. 
  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. Periodontal scaling and root 
planing - one to three teeth per quadrant (D4342) and extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D4342 and D7140 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal scaling and root planing - one to three teeth per quadrant (D4342) and extraction, erupted tooth or 
exposed root (elevation and/or forceps removal) (D7140) provided on October 18, 2022, and October 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the request is not medically necessary, once the enrollees 
oxygen requirements have improved and their blood cultures have cleared they can safely receive continued 
care, including respiratory care, IV antibiotics, and gastric tube feedings in another setting, such as a Skilled 
Nursing Facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous. Completion of treatment at the current facility is recommended. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (D9222 and D9223), nitrous oxide (D9230), a 
consultation (D9310), and therapeutic parenteral drugs (D9612) provided on November 2, 2022, and November 
9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were referred to the provider and would 
like the dental services covered. The Plan denied your request. The Plan says your annual dental benefit for the 
year has already been exhausted. Also, the consultation and therapeutic parenteral drugs are not covered by the 
Plan. 
 
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. On April 22, 
2022, the Plan paid $166 for dental services. On August 29, 2022, the Plan paid $1,834 for dental services. For 
the year of 2022 the Plan paid $2,000 ($166 paid + $1,834 paid) for dental services; therefore, your annual 
dental maximum benefit for the year was exhausted on the date of service of August 29, 2022. Also, the 
consultation and therapeutic parenteral drugs are not covered under the Plans dental benefit. Therefore, we 
decided that the Plan does not have to pay for the anesthesia (D9222 and D9223), nitrous oxide (D9230), a 
consultation (D9310), and therapeutic parenteral drugs (D9612) provided on November 2, 2022, and November 
9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires physician oversight and nursing 
management to manage medical needs and ensure a safe return home. The Plan denied your request. The Plan 
says the services the enrollee needs can be provided safely in another setting such as a skilled nursing facility, 
home with home health services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the manual therapy (97140) provided on June 22, 2022.
You asked the Plan to pay for the manual therapy. You say that you are requesting a reconsideration of the
Plan's denial for payment. The Plan denied your request. The Plan says that the supplemental benefit for this
service has been exhausted.
The Plan must follow Medicare rules. Plan rules says that supplemental (extra) coverage is provided for up to
$500 every year for routine chiropractic, acupuncture, and naturopathic services combined. The records show
that the Plan has provided $500 towards routine chiropractic, acupuncture, and naturopathic services combined.
There is no provision in the Plan contract that would require the Plan to pay above the $500 benefit limit.
Therefore, we decided that the Plan does not have to pay for the manual therapy (97140) provided on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for the requested item or 
service 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 December 3, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2750).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary for the enrollee to receive 
the therapy services needed and to ensure a safe discharge home. The Plan denied your request. The Plan says 
the enrollee does not meet the Medicare criteria for admission to an inpatient rehabilitation. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH level of care is appropriate 
for the enrollee. The Plan denied your request. The Plan says the requested LTACH admission is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot return to a normal living 
environment until they can move around without assistance. The Plan denied your request. The Plan says an 
IRF admission is not medically necessary, and the enrollee's needs can be met in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back injection provided on October 26, 2022. 
 
You asked the Plan to pay for the back injection. You say that only part of the claim has been paid. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the back injection 
provided on October 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported porcelain fused to metal crown 
(D6059), and custom fabricated abutment  includes placement (D6057) for teeth #'s 14 and 19. 
 
You asked the Plan to pre-approve codes D6059 and D6057. You say that you want implants for your teeth and 
need them because you job depends on your teeth. The Plan denied your request. The Plan says these services 
are not covered under the benefit package. 
 
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 
abutment supported porcelain fused to metal crown (D6059), and custom fabricated abutment  includes 
placement (D6057) for teeth #'s 14 and 19.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on September 16, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that these services were authorized. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
services provided on September 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140) and endodontic 
therapy (D3330) provided by an out-of-network provider on May 24, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the Plan should cover at least 50% of the 
procedures. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
total amount billed for the limited oral evaluation was $115 and the total allowed amount was $38 leaving a 
difference of $77 ($115 amount billed - $38 amount allowed) which is the enrollees liability. The total allowed 
amount for the endodontic therapy was $569 with a coinsurance amount of $284.50 ($569 total allowed x 50% 
coinsurance). The amount billed was $1,576 with a difference amount of $1,007 ($1,576 billed - $569 
allowed). The total enrollee liability for the endodontic therapy was $1,291.50 ($284.50 coinsurance + $1,007 
difference). The total enrollee liability was $1,368.50 ($77 liability + $1,291.50 liability). Therefore, we 
decided that the Plan does not have to pay more for a limited oral evaluation (D0140) and endodontic therapy 
(D3330) provided by an out-of-network provider on May 24, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73562 provided on September 3, 2022. 
 
You asked the Plan to pay for procedure code 73562. 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 find that procedure code 73562 is not supported in the medical record. Specifically, code 99284 
(emergency department visit) was billed on the same date of service, with revenue code 450. This code has a status indicator of "V". Therefore, this makes code 73562 not separately payable. Therefore, we decided that 
the Plan does not have to pay for procedure code 73562 provided on September 3, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on January 23, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you fell in 
your home and could not get up. You also say that the ambulance crew came and saw nothing was bleeding, 
they sat you up and let you sit for a few minutes. The Plan denied your request. The Plan says these services 
are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 23, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on January 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility lab visit provided on November 28, 2022. 
 
You asked the Plan to pay for a nursing facility lab visit. You say that we depend on the facility staff to verify 
eligibility and to obtain authorization. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a nursing facility lab 
visit provided on November 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral device/appliance used to reduce upper airway 
collapsibility (E0486) provided on May 21, 2021. 
 
You asked the Plan to pay for the oral device/appliance. You say that this is a medical claim and needs to be 
paid. The Plan denied your request. The Plan says your request is not medically necessary because the records 
do not show that you had a sleep test that met the criteria or any documentation from the ordering/treating 
provider. 
 
The Plan follows Medicare rules. Medicare rules say that if all of the criteria listed in the Medicare rules 
section of this letter are not met, the custom fabricated oral appliance (E0486) will be denied as not reasonable 
and necessary. 
 
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 pay for the oral device/appliance. Our reviewer says 
that the oral device/appliance was not medically necessary. Our physician reviewer found the documentation 
provided does not meet the criteria for coverage for an oral device for the treatment of obstructive sleep apnea. 
 
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 oral device/appliance have not been met. Therefore, we decided that the 
Plan does not have to pay for the oral device/appliance used to reduce upper airway collapsibility (E0486) 
provided on May 21, 2021.