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

 We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) 
rendered by the out of network (OON) provider on December 10, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was provided 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 has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care, per day (99308) rendered by the out of network (OON) 
provider on December 10, 2019.
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 enrollee has a chest tube at this time. 
You also say that going to a facility that can help with the enrollee's needs and with their test tube will help 
with their respiratory needs. The Plan denied your request. The Plan says the enrollee's complex medical needs 
are being met in the current acute setting at this time. The Plan also says that transfer to a LTACH is not 
medically necessary. 
 
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 does not require services at the long-term acute care hospital (LTACH) 
that are not available at the acute care hospital where they are currently receiving care. The short-term acute 
care hospital can provide for all of the enrollee's present inpatient care needs and the enrollee is receiving an 
appropriate level of care in the present setting. Continued care in the short-term acute care hospital is 
appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation 
facility, a sub-acute rehabilitation facility or a skilled nursing facility. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for 50 units of CPT code J2260 provided from January 1, 2020
to January 6, 2020.
You asked the Plan to pay for 50 units of CPT code J2260. You say that you would like the Plan to reconsider
their denial of payment. The Plan denied your request. The Plan says the medical records do not support the
billing of 50 units of CPT code J2260.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units
provided for each procedure code.
We find that 50 units of CPT code J2260 are not supported in the medical record. The medical record only
supports 2 units of CPT code J2260. Based on this information, we decided that Medicare rules for coverage of
50 units of CPT code J2260 have not been met. Therefore, we decided that the Plan does not have to pay for 50
units of CPT code J2260 provided from January 1, 2020 to January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of 
intraoral x-rays provided on December 19, 2019. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that these services were medically necessary. The Plan denied your request. The Plan says these services 
are dental in nature, and are not covered under your medical benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the comprehensive oral 
evaluation and complete series of intraoral x-rays provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring 
(95940) provided on November 14, 2019. 
 
You asked the Plan to pay for continuous intraoperative neurophysiology monitoring. You say that you would 
like reconsideration because this is a legal mobile unit company that employs certified technicians to provide 
intraoperative monitoring services. The Plan denied your request. The Plan says the provider billed a CPT code 
that is not payable by Medicare for place of service 15 (mobile unit). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that CPT code 95940 is only billable with specific place of service codes. 
 
We find that CPT code 95940 is not supported in the record. Specifically, per Medicare guidance, 
reimbursement for CPT code 95940 may only be made when billed with Place of Service codes 19, 21, 22 or 
24. In this case, CPT code 95940 has been billed with Place of Service code 15. Based on this information, we 
decided that Medicare rules for coverage of continuous intraoperative neurophysiology monitoring have not 
been met. Therefore, we decided that the Plan does not have to pay for continuous intraoperative 
neurophysiology monitoring (95940) provided on November 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided on March 13, 2020. You asked the Plan to pay for the CGP testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the CGP testing have not been met. Therefore, we decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided on March 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy (D3310), internal root repair (D3333)
and cone beam CT capture (D0367) provided on January 28, 2020.
You asked the Plan to pay for endodontic therapy (D3310), internal root repair (D3333) and cone beam CT
capture (D0367). You say that you were not aware the procedure was not covered at the time of the request.
You say that the root canal saved the tooth and is worthy of some reimbursement. The Plan denied your
request. The Plan says the services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's 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
endodontic therapy (D3310), internal root repair (D3333) and cone beam CT capture (D0367) provided on
January 28, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided December 24, 2019 to December 27, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided December 24, 2019 to December 27, 2019.
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 for the occlusal guard provided on October 30, 2019. 
 
You asked the Plan to pay for the occlusal guard. You say that you were told that this procedure would be 
covered by your plan. The Plan denied your request. The Plan says your plan does not cover this procedure. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
occlusal guard provided on October 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the shoulder arthroscopy surgery with 
rotator cuff repair (29827) and the Part B prescription drugs (J0690, J1815, J2250, J3010, J3490, J7120, J1885) 
provided February 25, 2020 to February 26, 2020. 
 
You asked the Plan to waive the coinsurance 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 coinsurance 
has been applied correctly to the services provided. 
 
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 20% 
coinsurance for Part B prescription drugs administered and for outpatient surgery.  
 
You have been asked to pay a $1,494.92 coinsurance ($7,474.62 allowed amount x 20 % coinsurance) for the 
outpatient surgery and the Part B prescription drugs administered. 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 
coinsurance for the shoulder arthroscopy surgery with rotator cuff repair (29827) and the Part B prescription 
drugs (J0690, J1815, J2250, J3010, J3490, J7120, J1885) provided February 25, 2020 to February 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient stay for a unicompartmental knee 
replacement surgery. 
 
You asked the Plan to pre-approve the stay. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not have any of exclusionary criteria for an outpatient or ambulatory-
level procedure. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 stay. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee presents with persistent right medial knee pain. Functional limitations are noted in activities 
of daily living. Clinical exam findings are reported consistent with imaging findings of medial femoral condyle 
subchondral insufficiency with surrounding bony edema and radiographic evidence of medial compartment 
joint space narrowing/subchondral sclerosis. He has failed to improve with conservative treatment, including 
activity modification, medications, physical therapy, home exercise program, and corticosteroid injections. 
Under consideration is a request for inpatient admission for approved right knee medial compartment 
arthroplasty. There is no specific medical comorbidity reported by the provider to support the medical necessity 
of inpatient care over the currently approved outpatient observation level of care. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to Medicare rules. Therefore, this request for inpatient stay for the approved unicompartmental knee 
replacement surgery is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the stay have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an inpatient stay for a unicompartmental knee replacement surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot, insert, removable, molded to patient model, 
longitudinal/ metatarsal support, each (L3020) provided on December 4, 2019. 
 
You asked the Plan to pay for foot orthotics. You say that you and the provider were informed by the Plan via a 
phone call that orthotic inserts are covered with your plan. The Plan denied your request. The Plan says it was 
discovered that you placed a call to the Health Plan on October 23, 2019. The Plan states that you were 
informed that orthotic shoe inserts are only covered if a diabetic medical condition exists; therefore, no 
misinformation was provided to you. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot, insert, removable, molded to 
patient model, longitudinal/ metatarsal support, each (L3020) provided on December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prophylaxis, topical application of fluoride varnish, reline 
of mandibular partial denture, mandibular partial denture, rebase of mandibular partial denture, and resin-based 
composite provided from November 7, 2019 to January 2, 2020 by an OON provider. 
 
You asked the Plan to pay for the dental services. You say that it does not seem like the Plan wants to pay these 
providers because they are not in-network. The Plan denied your request. The Plan says the treating provider is 
OON. The Plan also says that no benefits are available for procedures performed by OON providers or outside 
of the providers contracted period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s 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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
prophylaxis, topical application of fluoride varnish, reline of mandibular partial denture, mandibular partial 
denture, rebase of mandibular partial denture, and resin-based composite provided from November 7, 2019 to 
January 2, 2020 by an OON provider.  
 
Your complaint about being dissatisfied with the Plan is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on 
November 11, 2019 out of network. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 Plan contract says outpatient mental health requires referral.  
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 outpatient mental health care provided to the enrollee on November 11, 2019 out of 
network.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced pneumatic compression device. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says you have 
not failed a 4-week trial of a basic lymphedema pump. 
 
The Plan follows Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications. 
 
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 requested device. Our physician 
reviewer found that the diabetic foot exam is demonstrating no edema or skin breakdown. You are non-toxic 
and afebrile. There is no evidence of proximal lymphedema. There is no evidence a basic pump has trialed, and 
failed. As such, this request is not 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 requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an advanced pneumatic compression device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on February 6, 2020 through 
February 8, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says CPT code 97161 was billed without a required 
therapy modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and rules. Based on this information, we decided that Medicare rules for coverage of the 
outpatient services have not been met. Specifically, CPT code 97161 is an always therapy code and was billed 
without the required therapy modifier. Therefore, we decided that the Plan does not have to pay for outpatient 
services provided on February 6, 2020 through February 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoroscopy (76000) provided on January 3, 2020. 
 
You asked the Plan to pay for the fluoroscopy. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the Medicare rule for payment of this claim has 
not been met as the professional interpretation of a diagnostic test must be separately billed with modifier ?26 
by the interpreting physician. 
 
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 76000 is not supported in the record. Specifically, payment for the technical component 
of radiology services is paid to the facility when rendered in a hospital setting. CPT code 76000 has not been 
billed with the appropriate modifier for the professional component of this service. Based on this information, 
we decided that Medicare rules for coverage of the fluoroscopy have not been met. Therefore, we decided that 
the Plan does not have to pay for fluoroscopy (76000) provided on January 3, 2020.