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

 
We decided that the Plan does not have to pay for the periodontal scaling and root planning (D4342) provided 
from November 1, 2022, to November 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would not have gotten these procedures if 
you were informed that your benefit would be exhausted. 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 November 1, 2022. 
Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planning (D4342) 
provided from November 1, 2022, to November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on January 4, 2023. 
 
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 this service is not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99213) provided on January 4, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the ultrasound provided on April 3, ,2023. 
 
You asked the Plan to waive the deductible for the ultrasound. You say that your Plan contract says you should 
only have up to a $100 copayment for this service The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient diagnostic tests and 
therapeutic services. Your contract with the Plan also says that you must pay a $100 copayment after meeting 
the deductible for in-network diagnostic tests provided at an outpatient hospital.  
 
 The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $750 deductible which applies to outpatient diagnostic tests and therapeutic services. 
This cost sharing is a contractual obligation that had not been met at the time the ultrasound was received on 
April 3, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the ultrasound 
provided on April 3, ,2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says an epidural 
steroid injection is not medically necessary.  
 
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 the injection. Our reviewer says that 
that the enrollee does not meet the coverage criteria. Our physician reviewer found that the enrollee has chronic 
knee, neck, and low back pain. The enrollee's physician plans on performing multiple procedures including a 
lumbar epidural steroid injection, a lumbar radiofrequency ablation, trigger point injections, genicular never 
blocks and a cervical epidural steroid injection all within a short time frame. However, per standard of care 
multiple procedures should not be performed on one patient within such a short time frame. The enrollee had 
only two months of pain relief after the last cervical epidural steroid injection. The LCD coverage criteria 
requires at least 50% pain relief at least three months. Therefore, the request is not medically reasonable and 
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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2331) for tooth number 5 
provided on January 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that his procedure was medically necessary. The 
Plan denied your request. The Plan says this service is not a covered benefit under your dental 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, 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 resin-
based composite (D2331) for tooth number 5 provided on January 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code K0004 billed with diagnosis codes M15.9 
and M19.90 provided on January 10, 2023. 
 
You asked the Plan to pay for procedure code K0004. 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. The rules say that health plans, physicians, hospitals, and other health 
care providers must comply with the Official International Classification of Disease, 10th Edition, Clinical 
Modification (ICD-10-CM) Coding Guidelines. 
 
We looked at the file and Medicare rules. In this case, coding guidelines state that a type 1 Excludes note is a 
pure excludes note. It means "Not Coded Here!" An Excludes1 note indicates that the code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
Diagnosis codes M15.9 and M19.90 should not be reported together. Therefore, we decided that the Plan does 
not have to pay for procedure code K0004 billed with diagnosis codes M15.9 and M19.90 provided on January 
10, 2023.
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 medically necessary for the enrollee 
to optimize their functional status before returning home. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for admission to an IRF.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on November 17, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration for the services 
provided. 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 lab testing provided on 
November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 21, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that this is supported in the records. 
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 subsequent nursing 
facility care provided on February 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ostectomy provided on January 26, 2023. 
 
You asked the Plan to pay for the ostectomy. You say that you are requesting reconsideration of the denied 
claim. 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 ostectomy provided 
on January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intraosseous nerve ablation. 
 
You asked the Plan to pre-approve the intraosseous nerve ablation. You say that the enrollee has chronic back 
pain due to degenerative disc disease that has resulted in development of vertebrogenic pain. Plan denied your 
request. The Plan says the intraosseous nerve ablation is not medically necessary. 
 
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 the intraosseous nerve ablation. Our 
reviewer says that the intraosseous nerve ablation is not medically necessary. Our physician reviewer found 
that the enrollee has chronic low back pain. The enrollee has tried physical therapy and has had medication 
trials. However, the request for the intraosseous nerve ablation is considered experimental and investigational. 
Therefore, the request is not medically reasonable and 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 the intraosseous nerve ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the intraosseous nerve ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care, and related services provided on 
November 18, 2022. 
 
You asked the Plan to pay for nursing facility care, and related services. You say that the provider is not aware 
when authorization is obtained. 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 nursing facility care, and 
related services provided on November 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home evaluation visit provided on February 24, 2023. 
 
You asked the Plan to pay for home evaluation visit. You say that it is the responsibility of the facility 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 home evaluation visit 
provided on February 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab testing on March 10, 2023, to March 
11, 2023. 
 
You asked the Plan to waive the copayment for lab testing. You say that you shouldn't be charged a copayment. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment per day, per provider, for Medicare-covered lab services. Covered services include but are not 
limited to laboratory tests. There were two days. 2 x $10 = $20. Therefore, results in the total cost sharing 
amount of $20. 
 
 You have been asked to pay a $10 copayment per day for lab testing. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and 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 waive the copayment for lab testing on March 10, 2023, to March 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on February 18, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for a home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. The Plan denied your request. The Plan says the service was not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home visit provided on February 18, 2023, by an 
out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
March 11, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you felt ignored by 
the provider. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for the emergency room services. This item/service falls within 
the emergency 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 emergency room 
services provided on March 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on March 07, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that the assisted living facility is responsible 
to obtain prior authorization for all patients. 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 home visit for 
evaluation provided on March 07, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on January 
7, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that the services were not rendered at 
a hospital. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for laboratory services provided at an outpatient hospital. 
 
 
 
 You have been asked to pay $26.51, which is less than the standard copayment for the lab services. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and 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 waive the copayment for the laboratory services provided on January 7, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on February 07, 
2023. 
 
You asked the Plan to pay for an outpatient mental health visit. You say that the records attached support the 
services provided. 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 an outpatient mental 
health visit provided on February 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98941) rendered by 
the out-of-network (OON) provider from February 11, 2022, through February 10, 2023.  
 
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 chiropractic manipulative 
treatments (98941) rendered by the out-of-network (OON) provider from February 11, 2022, through  
February 10, 2023.