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

 
We decided that the Plan does not have to pay for the laboratory services provided on July 06, 2023. 
 
You asked the Plan to pay for the laboratory services. 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 laboratory services 
provided on July 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive metabolic panel provided on September 13, 
2022. 
 
You asked the Plan to pay for comprehensive metabolic panel. You say that you are requesting reconsideration 
for 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 comprehensive 
metabolic panel provided on September 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0300) provided from June 19, 2023, 
to June 26, 2023. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT/HCPCS code. 
 
We find that the home health services at issue do not meet criteria for payment. Specifically, the services have 
not been reported with the correct revenue code (055x). Based on this information, we decided that Medicare 
rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not 
have to pay for home health services (G0300) provided from June 19, 2023, to June 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device. 
 
You asked the Plan to pre-approve the device. You say that you have ongoing pain due to spinal stenosis. You 
say that your pain prevents you from completing activities of daily living. The Plan denied your request. The 
Plan says the Vertiflex Superion device 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 device. Our reviewer says that the 
Vertiflex Superion device is not medically necessary. Our physician reviewer found that the requested device is 
FDA-approve. However, the Centers for Medicare & Medicaid Services (CMS) has determined that 
percutaneous image guided lumbar decompression (PILD) for lumbar spinal stenosis (LSS) is not reasonable 
and necessary and that it is only covered when it is part of a study. 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex Superion device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit for the evaluation of a new patient (99205) 
provided on August 4, 2022. 
 
You asked the Plan to pay for the physician service. You say that this should be reprocessed and paid. The Plan 
denied your request. The Plan says the enrollee has had a face-to-face evaluation with another provider of the 
same specialty within the past three years. 
 
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 99205 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and high 
level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on 
the date of the encounter. 
 
We find that CPT code 99205 is not supported in the medical record. Specifically, the documentation submitted 
indicates that this enrollee previously received professional services from a physician within the same group 
practice within the last three years. Based on this information, we decided that Medicare rules for coverage of 
the physician service have not been met. Therefore, we decided that the Plan does not have to pay for the office 
visit for the evaluation of a new patient (99205) provided on August 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hearing aids provided on June 8, 2023. 
 
You asked the Plan to waive the copayment for the hearing aids. You say that you are asking for 
reimbursement of your hearing aid 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 $599 
copayment per aid for Advanced Aids.  
 
You have been asked to pay a $599 copayment for each of the hearing aids. These items fall within the hearing 
services 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 hearing aids provided 
on June 8, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency care services provided by an out-of-network 
provider on March 1, 2022. 
 
You asked the Plan to pay for the emergency care services. You say that the claim was submitted within the 
payer limits. The Plan denied your request. The Plan says the claim was filed more than 1 calendar year from 
the date of service. 
 
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 emergency care services was not filed until August 11, 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 the emergency care services provided by an out-of-network 
provider on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wearable mobile cardiovascular telemetry services provided 
on June 27, 2023. 
 
You asked the Plan to pay for wearable mobile cardiovascular telemetry services. You say that you are 
requesting reconsideration for the denied claim. The Plan denied your request. The Plan says they have made 
several attempts to obtain information, non was received as of this time. They cannot determine how the 
enrollee came to the servicing provider, whether the services were performed as billed, or whether the services 
are 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 wearable mobile cardiovascular 
telemetry services have been met. The medical records are missing. Therefore, we decided that the Plan does 
not have to pay for wearable mobile cardiovascular telemetry services provided on June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on  
July 5, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 service provided was previously exhausted.   
Specifically, the Plans contract states that two comprehensive oral evaluations or related services are covered 
per year. You previously received a comprehensive oral evaluation on February 7, 2023, less than one year 
prior, which was paid for by the Plan. Additionally, you received a comprehensive periodontal evaluation on 
July 12, 2023, which is a related service, that was previously paid for by the Plan. Therefore, you have 
exhausted the allowable benefit for the service provided in this case. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral evaluation (D0150) provided on July 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown - porcelain/ceramic (D2740), and core 
buildup, including any pins when required (D2950) provided on August 8, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are disputing the annual maximum 
denial on the claim. The Plan denied your request. The Plan says the benefit for the requested item or service 
$500 dollar limit was 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the enrollee's annual maximum benefit for dental services has been exhausted. The records show that the 
Plan paid $305 under claim number ending in 12371 for dental services provided on March 1, 2023. This 
included a partial payment of $195 towards the crown and core buildup in dispute. Once this partial payment 
was made, the yearly benefit maximum was reached. Therefore, we decided that the Plan does not have to pay 
more for the crown - porcelain/ceramic (D2740), and core buildup, including any pins when required (D2950) 
provided on August 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic x-ray (D0330) and two dimensional 2D oral or 
facial photographic image (D0350) provided on July 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that you asked the staff to please double check your 
coverages before beginning services to assure any service provided is covered by your Plan. You also say you 
were advised that services rendered that day were covered. 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 panoramic x-ray (D0330) was exhausted on date of service July 19, 2023. The record 
also shows that 2D oral or facial photographic image (D0350) is excluded form this benefit. Therefore, we 
decided that the Plan does not have to pay for panoramic x-ray (D0330) and two dimensional 2D oral or facial 
photographic image (D0350) provided on July 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 25, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that you are requesting reconsideration 
for 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 subsequent nursing 
facility care provided on March 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive periodontal evaluation (D0180) and 
periodontal scaling and root planing (D4342) provided on August 16, 2023. 
 
You asked the Plan to pre-approve the dental services. You say that you did not have another primary care 
physician the moment you scheduled with another physician. 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 a comprehensive periodontal evaluation (D0180) was exhausted on date of service 
August 8, 2023. The record also shows that the dental benefit reached its annual maximum limit of $1,000 on 
date of service August 8, 2023. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive periodontal evaluation (D0180) and periodontal scaling and root planing (D4342) provided on 
August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on August 17, 2023. 
 
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 August 17, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy services were provided on August 
17, 2023. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the requested services are 
covered by Medicare only for diabetes and rental disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy services were provided on August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 9, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says 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 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 the laboratory services provided on May 9, 2023, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided on June 13, 2023. 
 
You asked the Plan to pay for immunization services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says you have Part D coverage as part of your Plan. You 
are able to submit a Part D reimbursement request once you have covered the cost of the service. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to immunization 
services. Therefore, we decided that the Plan does not have to pay for immunization services provided on June 
13, 2023.  
 
Benefits for immunization services 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for scanning computerized ophthalmic 
diagnostic imaging (92133) and visual field examination (92083) provided on August 15, 2023. 
 
You asked the Plan to waive the copayment for scanning computerized ophthalmic diagnostic imaging and 
visual field examination. You say that the same tests, same codes, and same provider have been covered in the 
past. You also say that you cannot find any coverage changes by the Plan from 2022 to 2023. 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 $25 
copayment for each Medicare-covered other diagnostic test.  
 
You have been asked to pay a $25 copayment for scanning computerized ophthalmic diagnostic imaging and 
visual field examination. This item/service falls within the Medicare-covered other diagnostic test 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 scanning computerized ophthalmic diagnostic 
imaging (92133) and visual field examination (92083) provided on August 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wearable mobile cardiovascular telemetry services provided 
on June 6, 2023. 
 
You asked the Plan to pay for wearable mobile cardiovascular telemetry services. You say that you are 
requesting reconsideration for the denied claim. The Plan denied your request. The Plan says they have made 
several attempts to obtain information, none was received as of this time. 
 
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 wearable mobile cardiovascular 
telemetry services have been met. The medical records are missing. Therefore, we decided that the Plan does 
not have to pay for wearable mobile cardiovascular telemetry services provided on June 6, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on July 10, 2022. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. The Plan denied your 
request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period.  
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the ED services provided on July 10, 2022.