Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on  
August 16, 2021, and August 24, 2021.  
 
You asked the Plan to pay for subsequent 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 subsequent 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 subsequent nursing facility care provided on 
August 16, 2021, and August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neurology visit with the requested provider. 
 
You asked the Plan to pre-approve a neurology visit with the requested provider. You say that you could not 
find a doctor in-network with the same qualifications as the requested provider. The Plan denied your request. 
The Plan says the services are available at a contracted facility. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is 
not providing these services and is not making arrangements to provide these services. Therefore, we decided 
that the Plan does not have to pre-approve a neurology visit with the requested provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided on 
November 17, 2022. 
 
You asked the Plan to pay for the psychiatric service. You say that you do not remember having this 
evaluation. The Plan denied your request. The Plan says the provider does not participate with Medicare. The 
Plan says that payment cannot be made for services performed by a provider that does not participate with 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation 
(90791) provided on November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service August 30, 
2022. 
 You asked the Plan to pay for procedure code 11721. You say that the physician provided medically necessary 
services, so this service should be covered. The Plan denied your request. The Plan says payment for code 
11721 is bundled into payment for code 11055. 
 
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 11721 
is a column II code to column I code 11055. 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 11721 billed for date of service August 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test provided on December 15, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test provided on December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on October 21, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you do not agree with the fact your 
insurance did not pay the full amount for services you received. 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. This benefit includes the 
requested item or service but is limited to a maximum of $2,500 every year. After the annual maximum is 
exhausted, any remaining charges are the members responsibility. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your Plan paid $96 on March 1, 2022, $500 on June 4, 2022, $580 on August 15, 2022, $580 on August 
16, 2022, $140.80 on September 14, 2022, $603.20 on October 21, 2022 ($96 + $500 + $580 + $580 + $140.80 
+ $603.20=$2,500). Therefore, this benefit has been exhausted. Therefore, we decided that the Plan does not 
have to pay more for dental services provided on October 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for caries risk assessment and documentation, with a finding of 
moderate risk (D0602) provided on February 23, 2022. 
 
You asked the Plan to pay for the caries risk assessment and documentation. You say that you were told all 
services received by the dentist would be covered. You also say that now you have received a denial of 
payment letter for the services. The Plan denied your request. The Plan says this service is not covered under 
the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, 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 caries risk 
assessment and documentation, with a finding of moderate risk (D0602) provided on February 23, 2022.
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 reconsideration for the denial of 
a SNF admission based on medical necessity. The Plan denied your request. The Plan says admission to a SNF 
is not medically necessary at this time. 
 
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 initial nursing facility care provided on October 26, 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  
October 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 2, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that this was not an accident related claim. The 
patient was found to have a fracture of the right foot of unknown etiology. Please see attached ambulance run 
report and physician order for review. The Plan denied your request. The Plan says the member did not respond 
to plan attempts to obtain possible accident details. The Plan has denied claims until the member responds to 
us. 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed 
with the provider that the claim was submitted to the primary insurance carrier, but they have not received the 
primary insurance payment information. As the secondary insurer, the Plan cannot be held responsible for the 
ambulance services until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for ambulance services provided on February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite-three surfaces, posterior (D2393) 
provided on January 16, 2023. 
 
You asked the Plan to pay for this item. 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 item 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 item provided was exhausted on date of service January 16, 2023.  
  
Specifically, the Plans contract provides coverage for one resin-based composite every six months. On this 
day, you received three resin-based composites, in which two were paid for by the Plan. Therefore, you have 
exhausted the allowable benefit for this dental item at this time. Therefore, we decided that the Plan does not 
have to pay for the resin-based composite-three surfaces, posterior (D2393) provided on January 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle orthosis (L1902) provided on November 9, 2022. 
 
You asked the Plan to pay for the ankle orthosis. You say that this item was medically necessary. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for an ankle orthosis (L1902) 
provided on November 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound guided radiofrequency ablation (60699) 
provided February 24, 2022. 
 
You asked the Plan to pay for the procedure. You say that you paid $5,000 upfront and you need to be 
reimbursed. The Plan denied your request. The Plan says documentation is needed from the physician to 
support medical necessity. 
 
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 pay for the procedure. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records do not indicate why the nodule was treated in this way. The records do not indicate 
if this is a hot or toxic nodule or if the nodule has been biopsied and is known to be benign. Without knowing why the nodule was treated with radiofrequency ablation, we cannot say that it is medically 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pay for an ultrasound guided radiofrequency ablation (60699) provided February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on  
August 16, 2021. 
 
You asked the Plan to pay for the subsequent 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 subsequent 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 subsequent nursing facility care provided on 
August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212), manual therapy (97140), and the 
acupuncture treatments (97813, 97814) rendered by the out-of-network (OON) provider on August 4, 2022. 
 
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 office visit (99212), manual therapy (97140), and the acupuncture treatments 
(97813, 97814) rendered by the out-of-network (OON) provider on August 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on December 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with these charges. 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 $2,500 combined allowance for dental services was exhausted on date of service December 13, 
2022. Any amount over $2,500 is the enrollees responsibility. Therefore, we decided that the Plan does not 
have to pay for dental services provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120) on 
November 28, 2022. 
 
You asked the Plan to pay for dental services. You say that you could not find an appointment within a 
reasonable time-frame for what you needed. The Plan denied your request. The Plan says the provider you 
received services from is a Medicare opt-out provider; therefore, you cannot receive reimbursement. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for periodic 
oral evaluation - established patient (D0120) on November 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (84443, 82607, 82306, 36415) 
provided on August 29, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee should be covered. The Plan 
denied your request. The Plan says these services are not covered because they were provided OON. 
 
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 the laboratory services (84443, 82607, 82306, 
36415) provided on August 29, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on November 18, 
2022. 
 
You asked the Plan to waive the copayment for ultrasound. 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 $185 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $185 copayment for ultrasound. 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 ultrasound provided on November 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29877 billed for date of service November 
28, 2022. 
 
You asked the Plan to pay for procedure code 29877. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 29877 is bundled into payment for code 29880. 
 
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 29877 is a column II code to column I code 29880 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 29877 billed for date of service November 28, 2022.