Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from March 1, 2020, to March 3, 
2020. 

You asked the Plan to pay for inpatient care. You say that the Plan was not prompt with a transfer. The Plan 
denied your request. The Plan says the enrollee was stabilized by 11:50 PM on February 29, 2020. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient care. Our reviewer says that the 
criteria for coverage of these services have not been met. Our physician reviewer found the enrollee was 
hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility for 
observation/admission level of care services after the emergency room evaluation.  All inpatient care provided 
after 11:50 pm on February 29, 2020 was not needed on an emergent basis. The post-stabilization care services 
from March 1, 2020, to March 3, 2020 were not medically necessary or reasonable. The review indicates that 
the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was 
not stable for transfer on any dates of service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient care provided from March 1, 2020, to March 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urinalysis (81001) provided on May 11, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for urinalysis. You say that medically necessary services were rendered in good 
faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered 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 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 has network providers 
available who can provide 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 urinalysis (81001) provided on May 11, 2020 
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that this is a medically reasonable and 
necessary treatment. The Plan denied your request. The Plan says there is not enough evidence 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 pre-approve the Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy of 
the device. 
 
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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided to 
the enrollee on April 21, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare requires use of CPT 81479 to report comprehensive genomic profile (CGP) testing. 
 
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 81404 is not supported in the medical record. Specifically, this test should be reported 
with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the services have 
not been met. Therefore, we decided that the Plan does not have to pay for comprehensive genomic profile 
(CGP) testing provided to the enrollee on April 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation for an extraction to be provided by an 
oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that you are on Flosamax. You say that a 
general dentist would not do the extraction due to this. You also say that you were referred to an oral surgeon. 
The Plan denied your request. The Plan says Services must be performed by a participating general dentist. The 
Plan also says services provided by oral surgeons are not covered. 
 
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 when provided by an oral surgeon. Therefore, we decided that the Plan 
does not have to pre-approve a consultation for an extraction to be provided by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy provided to the enrollee on April 
22, 2020. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that this claim should be paid. The 
Plan denied your request. The Plan says the enrollee did not have a qualifying diagnosis for this service. 
 
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 suffered from renal 
disease or diabetes. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy 
provided to the enrollee on April 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation 
(D7953). 
 
You asked the Plan to pre-approve the bone replacement graft. You say that you need this approved for 
surgery. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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 pre-approve a 
bone replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup, including any pins 
when required (D2950). 
 
You asked the Plan to pre-approve the crown and core buildup. You say that you have trouble eating because 
your tooth breaks and causes you pain. The Plan denied your request. The Plan says these services are not 
covered under your dental plan. 
 
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 pre-approve a 
crown (D2740) and core buildup, including any pins when required (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99214) provided on March 9, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for outpatient office visit. You say that telemedicine does not require prior 
authorization. The Plan denied your request. The Plan says prior authorization must be obtained for non-
emergent services rendered 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 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 has network providers 
available who can provide 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 outpatient office visit (99214) provided on 
March 9, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for breast reconstruction (19366) provided on March 4, 2020 
 
You asked the Plan to pay for breast reconstruction. You say that this is shown in the operative report. The Plan 
denied your request. The Plan says that this code is not substantiated. 
 
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 19366 is breast reconstruction with other technique. 
 
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 breast reconstruction. Our reviewer says that 
the use of this code is supported. Our physician reviewer found the submitted medical records, specifically the 
operative report, document procedures that meet criteria for this code. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of breast reconstruction have been met. Therefore, we decided that the Plan has to 
pay for breast reconstruction (19366) provided on March 4, 2020  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the inpatient hospital care provided from May 
29, 2020, to June 16, 2020. 

You asked the Plan to waive the copay for the inpatient services. You say that the enrollee was moved from the 
hospital to a nursing facility. The Plan denied your request. The Plan says the copay was applied appropriately. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $300 copay per day for days 1-5 for inpatient hospital care.  
 
The file shows that the enrollee received inpatient rehabilitation care. The enrollee has been asked to pay a 
$300 copay per day for days 1-5 for the inpatient services. The services fall within the inpatient hospital care 
benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract 
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copay for the inpatient hospital care provided 
from May 29, 2020, to June 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the nutritional shakes purchased from March 31, 
2020, to May 29, 2020. 
 
You asked the Plan to reimburse you for the nutritional shakes. You say that your neurologist wants you to 
drink one shake a day. The Plan denied your request. The Plan says nutritional shakes are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
nutritional shakes is an OTC item. Medicare rules say that enteral nutrition products administered orally are not 
covered. The Plan has a supplemental OTC benefit. Nutritional shakes are not covered by the Plan. Therefore, 
we decided that the Plan does not have to reimburse you for the nutritional shakes purchased from March 31, 
2020, to May 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Superion 
Vertiflex). 
 
You asked the Plan to pre-approve Vertiflex. You say that this is medically necessary and should be covered. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because 
current medical literature indicates that Vertiflex is considered experimental/investigational. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this device is experimental, more research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of an interspinous spacer device (Superion Vertiflex).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional 15 minutes of deep sedation (D9223 x 3). 
 
You asked the Plan to pre-approve 3 additional 15 minutes of deep sedation. You say that you need the 
extractions. The Plan denied your request. The Plan says deep sedation is not a covered service. 
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
additional 15 minutes of deep sedation (D9223 x 3).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on 
January 6, 2020 to May 30, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that provider refused to send a fax 
on your behalf. The Plan denied your request. The Plan says the provider who rendered the service is not an In 
Network provider and you do not have a referral from your Primary Care Physician for the services provided. 
 
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 has network providers 
available who can provide 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 chiropractic manipulative treatment (98941) 
provided on January 6, 2020 to May 30, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an ultrasound scan of extremity (93971) 
performed on April 24, 2020, and a CT scan of the face (70486) performed on April 27, 2020. 
 
You asked the Plan to waive the copayments for an ultrasound scan of extremity and a CT scan of the face. 
You say that your medical issues were due to you contracting COVID-19. The Plan denied your request. The 
Plan says the correct copayment was applied. 
 
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 $160 
copayment for each Medicare-covered radiological diagnostic service, not including X-rays.  
 
The Plan waived copayments for selected services related to treatment of COVID-19, effective on May 11 to 
September 30, 2020. An ultrasound scan of extremity and a CT scan of the face were performed outside of this 
timeframe. Therefore, you have been asked to pay a $149.70 copayment for an ultrasound scan of extremity 
and a $160 copayment for a CT scan of the face. An ultrasound scan of extremity and a CT scan of the face fall 
within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means 
that you have been asked to pay less than or equal to the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayments for an ultrasound scan of extremity (93971) 
performed on April 24, 2020, and a CT scan of the face (70486) performed on April 27, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility care to be provided by an out 
of network (OON) provider. 
 
You asked the Plan to pre-approve the skilled nursing facility care. You say that you prefer the out of network 
facility because of religious reasons. The Plan denied your request. The Plan says the requested services can be 
provided at multiple in-network skilled nursing facilities. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the skilled nursing facility care to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prolonged services provided on December 9, 2019. 
 
You asked the Plan to pay for prolonged services (99356). You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says submitted progress notes do not include time spent on prolonged 
services in addition to primary evaluation and management care, therefore the billed service cannot be verified.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must produce medical records to 
support the services billed. 
 
In this case, the CPT Code Manual definition of code 99356 is Prolonged service in the inpatient or observation 
setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for 
inpatient Evaluation and Management service). 
 
We find that CPT code 99356 is not supported in the medical record. In this case, there were insufficient 
records provided to support the claim billed. There is no documentation of direct face-to-face patient contact 
one hour beyond the usual service. In the hospital setting, time spent reviewing charts or discussing the patient 
with house medical staff and not with direct face-to-face contact with the patient or waiting for test results, for 
changes in the patient?s condition, for end of a therapy, or for use of facilities, cannot be billed as prolonged 
services. Medicare billing criteria are not met. Based on this information, we decided that Medicare rules for 
coverage of prolonged services (99356) have not been met. Therefore, we decided that the Plan does not have 
to pay for prolonged services provided on December 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 extractions and a consultation with an oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that your tooth broke. You say that the other 
teeth are effecting your health. You say that you have health issues and a bad back. You also say that you do 
not want to catch an infection because he does not want to end up in the hospital with the current pandemic. 
The Plan denied your request. The Plan says dental services are only covered when they are performed by a 
participating general dentist. The Plan also says dental services performed by an oral surgeon are not covered.  
 
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 when you receive them from an oral surgeon. Therefore, we decided 
that the Plan does not have to pre-approve 7 extractions and a consultation with an oral surgeon.