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

 
We decided that the Plan does not have to pay for the specialist office visit and the laboratory services provided 
on April 17, 2023, by an OON provider.  
 You asked the Plan to pay for the specialist office visit and laboratory services. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says these services are not covered 
when received by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has a POS option to use either network providers or out-of-network providers for certain 
covered services. The Plan contract also says that out-of-network laboratory and physician services are not 
covered. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
items/services 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 specialist office visit and the laboratory 
services provided on April 17, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 29, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration stating the plan 
denied the claim for no 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 an office visit provided 
on June 29, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 3, 2022, to 
October 2, 2022. 
 You asked the Plan to pay for home health services. You say that you have reported the services at issue 
correctly. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final 
claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is May 6, 2022. The NOA was not received by the Plan until January 12, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from September 3, 2022, to October 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on May 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have been seeing the provider for years. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services provided on May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercise provided by a chiropractor on May 
11, 2023. 
 
You asked the Plan to pay for the therapeutic exercise provided by a chiropractor. You say that you do not 
agree with the denial of payment for the service you received. The Plan denied your request. The Plan says this 
service is not covered when it is billed by a chiropractor. 
 
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 therapeutic exercise provided by a chiropractor on May 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation with a medicinal agent  per quadrant 
(D4921) provided on May 17, 2023. 
 
You asked the Plan to pay for the dental service. You say that there is no limitation listed in the EOC. The Plan 
denied your request. The Plan says your benefit for the gingival irrigation with a medicinal agent 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 service was exhausted on date of service January 24, 2023. Therefore, we 
decided that the Plan does not have to pay for the gingival irrigation with a medicinal agent  per quadrant 
(D4921) provided on May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (82565, 84315, G0481) billed for date of 
service February 22, 2023. 
 
You asked the Plan to pay for laboratory services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says the provided records do not support the services billed. 
 
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 laboratory services have been met. 
Specifically, the case record does not contain a physician order or requisition form for the services at issue. 
Therefore, we decided that the Plan does not have to pay for laboratory services (82565, 84315, G0481) billed 
for date of service February 22, 2023.
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 May 3, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. 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 May 3, 2023. 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 May 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5211). 
 
You asked the Plan to pre-approve a partial upper denture. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 a partial upper denture have been met. 
Specifically, medical records were requested but not received. Medical necessity cannot be established without this documentation. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture 
(D5211).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided from May 23, 
2023, through May 24, 2023. 
 
You asked the Plan to pay for the medication. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided from May 23, 2023, through May 24, 2023.  
 
Benefits for the medication 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: 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 enrollee cannot go to a lower level of 
care because they are medically complex with a need for continuous and daily physician care. You also say the 
enrollee is too medically complex with too many clinical care needs for a skilled nursing facility (SNF) and is 
unable to tolerate 3 hours of therapy required in an acute inpatient rehabilitation facility (IRF). The Plan denied 
your request. The Plan says the records do not show that it is medically necessary to be in an LTACH in place 
of an acute care hospital.  
 
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 the record indicates the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied.   
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee to be weaned off the ventilator. The Plan denied your request. The Plan says the enrollee can safely 
receive the services that they need in the current hospital. 
 
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 the enrollee continues to receive acute care services and these have not been denied. 
The medical record does not indicate that the enrollee requires services that they are not currently receiving but 
that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The 
requested service cannot be 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87506 for date of service January 30, 2023. 
 
You asked the Plan to pay for procedure code 87506. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported as billed. 
 
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 87506 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 6-11 targets. 
 
 
 We find that CPT code 87506 is not supported in the medical record. Specifically, there is a more appropriate 
lab panel code that should be billed when one or more codes are included in the same panel. Based on this 
information, we decided that Medicare rules for coverage of procedure code 87506 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 87506 for date of service January 
30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the bitewings - four radiographic images D0274), and 
periodontal scaling and root planing - one to three teeth per quadrant (D4342) provided on June 20, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you have primary coverage but the dentist 
does not accept it. You also are asking for a review for coverage payment. 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 the bitewings - four radiographic images 
D0274), and periodontal scaling and root planing - one to three teeth per quadrant (D4342) provided on June 
20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an OON provider on December 
14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told this would be covered and you 
cannot afford the payment. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an OON provider on December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110) provided on May 16, 2023. 
 
You asked the Plan to pay for the chiropractor services. You say that these services have given you relief from 
your pain and denying payment is not fair. The Plan denied your request. The Plan says this chiropractic 
service is excluded from coverage. 
 
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 therapeutic exercises (97110) provided on May 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0220 and D0230), a 
cone beam (D0364), the pulp vitality tests (D0460), the therapeutic pulpotomy (D3220), the endodontic therapy 
(D3330), and an occlusal adjustment (D9951) and to waive the coinsurance for a limited oral evaluation 
(D0140) provided by an out-of-network provider on June 1, 2023, and July 6, 2023. 
 
You asked the Plan to pay and to waive the coinsurance for the dental services. You say that endodontics is 
covered under your plan overview at 80%. The Plan denied your request. The Plan says the denial of payment 
for the intraoral radiographic images, a cone beam, the pulp vitality tests, the therapeutic pulpotomy, the 
endodontic therapy, and an occlusal adjustment is correct because they are not covered by the Plan. Also, the 
proper cost share was applied. 
 
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 intraoral radiographic images, a 
cone beam, the pulp vitality tests, the therapeutic pulpotomy, the endodontic therapy, and an occlusal 
adjustment are not among those covered under this benefit. Your contract with the Plan clearly says that you 
must pay a 30% coinsurance for a limited oral evaluation when received from an out-of-network provider. 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 for the intraoral radiographic images (D0220 and D0230), a cone beam 
(D0364), the pulp vitality tests (D0460), the therapeutic pulpotomy (D3220), the endodontic therapy (D3330), 
and an occlusal adjustment (D9951) and to waive the coinsurance for a limited oral evaluation (D0140) 
provided by an out-of-network provider on June 1, 2023, and July 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on August 04, 2022. 
 
You asked the Plan to pay for an annual wellness visit. 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 an annual wellness visit 
provided on August 04, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services you require can safely be received at a different setting, for 
example, home with home health, in residential care, or home with close follow-up with your doctor. 
 
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 have daily skilled nursing needs that require the specialized skill, knowledge, 
and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 skilled nursing facility (SNF) care.