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

 
We decided that the Plan does not have to pay more for dental services provided on November 16, 2022. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. 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. 
Therefore, we decided that the Plan does not have to pay more for dental services provided on November 16, 
2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for an ultrasound of the heart with color-depicted blood flow, rate, 
direction, and valve function (93306) provided on January 02, 2023. 
 
You asked the Plan to pay for the ultrasound. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that this claim has not been billed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the governing Local Coverage Article does not explicitly state that 
specific diagnosis codes must be billed for the service at issue. Therefore, we decided that the Plan has to pay 
for an ultrasound of the heart with color-depicted blood flow, rate, direction, and valve function (93306) 
provided on January 02, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2751) and the core buildup (D2950) for 
tooth #19 provided on September 1, 2022, and September 22, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you feel the service should be covered. 
The Plan denied your request. The Plan says your dental maximum benefit for the year 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 on February 11, 2022, the Plan paid $85.50 for dental services. On April 14, 2022, the Plan paid $123 
for dental services. On May 3, 2022, the Plan paid $440 for dental services. On August 1, 2022, the Plan paid 
$30 for dental services. On August 9, 2022, the Plan paid $9.50 for dental services. On August 16, 2022, the 
Plan paid $100.50 for dental services. On September 22, 2022, the Plan paid $165.50 for dental services. On 
October 19, 2022, which was processed prior to this claim the Plan paid $169 for dental services. On October 
31, 2022, which was processed prior to this claim the Plan paid $367.50 for dental services. On December 21, 
2022, which was processed prior to this claim the Plan paid $9.50 for dental services. For the year of 2022 the 
Plan paid $1,500 ($85.50 paid + $123 paid + $440 paid + $30 paid + $9.50 paid + $100.50 paid + $165.50 paid 
+ $169 paid + $367.50 paid + $9.50 paid) for dental services; therefore, your dental benefit for the year of 2022 
was exhausted prior to when the claim for September 1, 2022, and September 22, 2022, was processed. 
Therefore, we decided that the Plan does not have to pay more for a crown (D2751) and the core buildup 
(D2950) for tooth #19 provided on September 1, 2022, and September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that you have arthritis in both hands, 
painful mobility and it is painful to be pricking your fingers twice a day and occasionally 3 times. The Plan 
denied your request. The Plan says you do not require insulin three or more times daily. 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a vaccination provided on December 16, 2022. 
 
You asked the Plan to pay for a vaccination. You say that this should be considered a routine injection. There is 
a unique relationship between the Plan and the hospital. 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 vaccination provided 
on December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided on August 17, 2022. 
 
You asked the Plan to pay for the critical care services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code 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. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, this code is included in the 
global surgical package of code 49205 which was also billed. Based on this information, we decided that 
Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan 
does not have to pay for critical care services (99291) provided on August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on December 09, 2022, to 
December 30, 2022. 
 
You asked the Plan to pay for the chiropractic services. You say that this provider is the only one within 
reasonable distance. 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 chiropractic services 
provided on December 09, 2022, to December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care provided on November 5, 2021. 
 
You asked the Plan to pay for the initial nursing facility care. You say that the claim was filed timely. The Plan 
denied your request. The Plan says the provider did supply evidence that claim was attempted to be billed once 
before, but provider failed to re-file claim within timely file, despite being timely notified of rejection of initial 
claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the initial nursing facility care was not filed until January 18, 2023. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for initial nursing facility care provided on 
November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visits provided on 
December 12, 2022, and January 16, 2023. 
 
You asked the Plan to waive the copayments for the specialist office visits. You say that you must pay a 
deductible and 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 $15 
copayment for each specialist office visit.  
 
You have been asked to pay a $15 copayment for each specialist office visit. You have been asked to pay a 
total of $30 ($15 copayment x 2 visits = $30). These items/services fall within the physician/practitioner 
services, including doctor's office visits 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 copayments 
for the specialist office visits provided on December 12, 2022, and January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care provided from December 8, 2021, 
to December 20, 2021.  
 
You asked the Plan to pay for the initial nursing facility care. You say that the claim was filed timely. The Plan 
denied your request. The Plan says the provider did supply evidence that claim was attempted to be billed once 
before, but provider failed to re-file claim within timely file, despite being timely notified of rejection of initial 
claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the initial nursing facility care was not filed until January 18, 2023. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for initial nursing facility care provided from 
December 8, 2021, to December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care provided from December 8, 2021, 
to December 18, 2021. 
 
You asked the Plan to pay for the initial nursing facility care. You say that the claim was filed timely. The Plan 
denied your request. The Plan says the provider did supply evidence that claim was attempted to be billed once 
before, but provider failed to re-file claim within timely file, despite being timely notified of rejection of initial 
claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the initial nursing facility care was not filed until January 18, 2023. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for initial nursing facility care provided from 
December 8, 2021, to December 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Jardiance. 
 
You asked the Plan to pre-approve Jardiance. You say that Jardiance is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Jardiance.   
Benefits for Jardiance may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29125 billed for date of service December 
29, 2022. 
 You asked the Plan to pay for procedure code 29125. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 29125 is bundled into payment for code 25605. 
 
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 29125 
is a column II code to column I code 25605. 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 procedure code 29125 billed for date of service December 29, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Multi-Gene Testing provided on November 
22, 2022. 
 
You asked the Plan to pay for the GeneSight Multi-Gene Testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the GeneSight Multi-
Gene Testing have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight 
Multi-Gene Testing provided on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine (90750) provided on October 6, 2022. 
 
You asked the Plan to pay for the vaccine service. You say that this should be covered. The Plan denied your 
request. The Plan says the shingles vaccine is not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine service. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
service. Therefore, we decided that the Plan does not have to pay for the shingles vaccine (90750) provided on 
October 6, 2022.  
 
Benefits for the vaccine service may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab testing provided on December 06, 2022. 
 
You asked the Plan to waive the copayment for lab testing. You say that you are disputing the share cost. 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 $15 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $15 copayment 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 provided on December 06, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation - per quadrant (D4921), re-evaluation, 
limited, problem focused (D0170), mandibular partial denture (D5214) and bone replacement graft for ridge 
preservation - per site (D7953) provided on December 3, 2022, to December 9, 2022. 
 
 
You asked the Plan to pay for gingival irrigation, re-evaluation, limited, mandibular partial denture and a bone 
replacement graft. You say that this should be covered. The Plan denied your request. The Plan says these are 
not covered services. 
 
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 gingival 
irrigation - per quadrant (D4921), re-evaluation, limited, problem focused (D0170), mandibular partial denture 
(D5214) and bone replacement graft for ridge preservation - per site (D7953) provided on December 3, 2022, 
to December 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and ear wax removal (69209) 
provided on May 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you have never had to have authorization. 
You also say that when you took out this insurance you made sure no authorization was needed. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The 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. Therefore, we 
decided that the Plan does not have to pay for the office visit (99213) and ear wax removal (69209) provided 
on May 23, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting an expedited reconsideration 
for the denial of a SNF admission. The Plan denied your request. The Plan says admission to a SNF is not 
medically necessary, reasonable, and appropriate for your condition. 
 
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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist; however, you do not require 
skilled therapy services on a daily basis. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (SNF) setting. You do not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided on September 02, 2022, to 
September 28, 2022. 
 
You asked the Plan to pay for the office visits. You say that you were informed that the provider was in-
network. 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 office visits provided 
on September 02, 2022, to September 28, 2022.