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

 
We decided that the Plan does not have to pay for observation care provided on July 1, 2019. 
 
You asked the Plan to pay for observation care. You say that the claim was timely. The Plan denied your 
request. The Plan says the claim was untimely. 
 
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 observation care was not filed until July 9, 2020. 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 observation care provided on July 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urology services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says the requested 
provider is not a primary network doctor. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
urology services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral exam (D0120) and prophylaxis (D1110) provided 
on May 20, 2020, and extraction (D7140) provided on September 28, 2020. 
 
You asked the Plan to pre-approve oral exam, prophylaxis and extraction. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the services are covered when provided by a 
participating provider. 
 
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. Specifically, you received these services from a non-participating 
provider. These services are only covered when provided by a participating provider. Therefore, we decided 
that the Plan does not have to pre-approve oral exam (D0120) and prophylaxis (D1110) provided on May 20, 
2020, and extraction (D7140) provided on September 28, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee is experiencing weakness. The Plan 
denied your request. The Plan says the enrollee's needs are custodial. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 services. Our physician reviewer 
found that the enrollee is able to ambulate household distances with a walker and contact guard assistance. She 
also requires contact guard assistance for transfers, toileting and stand by assistance for bed mobility. She is 
tolerating an oral diet and has baseline mild confusion. She does not have any parental medication, complex 
wound care, or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of 
chronic medical problems. Her physical function is at or near her baseline. The enrollee does not require skilled 
nursing and/or skilled therapy services on a daily basis. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist hand orthosis (L3916) provided on June 15, 2020. 
 
You asked the Plan to pay for a wrist hand orthosis. You say that this is supported in the records. The Plan 
denied your request. The Plan says there is not a valid proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The delivery slip in 
the file is not itemized and the itemized invoice does not include the carrier's tracking number. 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 a wrist hand orthosis (L3916) provided on June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (CPT 00400) provided to the enrollee on 
June 15, 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 the diagnosis codes are mismatched. 
 
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 00400 is "Anesthesia for procedures on the 
integumentary system on the extremities, anterior trunk and perineum; not otherwise specified." 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found per the 
documentation submitted, the diagnosis is "mass to upper right and left upper arm, 2 cm in size", and reported 
two separate codes for each arm, when there is one code that includes both arms (bilateral). If there is no 
"bilateral code" then it would be appropriate to report with appropriate code(s) or appropriate modifier. In this 
case, there is a "bilateral code" which should be reported. 
 
We looked at this coder's review, the file, and Medicare rules. 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 anesthesia services (CPT 00400) provided to the enrollee on June 15, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve spinal injection services 
 
You asked the Plan to pre-approve the spinal injections. You say that the enrollee is in a lot of pain. You say 
that the enrollee received a lumbar branch block trial on February 2, 2021, in which he received 90% relief of 
pain. You say that the documentation provided supports the services in dispute. The Plan denied your request. 
The Plan says that the records provided do not support that the criteria for coverage have been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 spinal injections. Our reviewer says 
that the requested spinal injections are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic low back pain. He takes Norco for pain. He had an L4 
radiculopathy in the past and has the beginnings of a RED flag symptom of incontinence. On MRI he has 
multi-level degenerative disc disease as well as facet arthropathy and L4 nerve root foraminal stenosis. He had 
diagnostic MBBs and by his pain diary, he had 80% pain relief. Our physician reviewer found that the enrollee 
meets the criteria for coverage of the requested injection services and that they are 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 spinal injections have been met. Therefore, we decided that the Plan has to 
pre-approve spinal injection services  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 7, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 physician's services provided on October 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient diagnostic tests provided on 
September 3, 2020. 
 
You asked the Plan to waive the coinsurance for the outpatient diagnostic tests. You say that your doctor made 
these tests. The Plan denied your request. The Plan says you were charged the coinsurance 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 30% 
coinsurance for Out of Network Outpatient Diagnostic Tests.  
 
You have been asked to pay 30% coinsurance for the outpatient diagnostic tests. The outpatient diagnostic tests 
fall within the Out of Network Outpatient Diagnostic Tests 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 coinsurance for the outpatient diagnostic tests provided on September 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 23, 
2020, to February 25, 2020. 
 
You asked the Plan to pay for the inpatient services. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says medical necessity was not met for an inpatient level of care. 
 
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 the inpatient services. Our physician 
reviewer found that the enrollee was recently treated for a urinary tract infection (UTI). He was diagnosed with 
gross hematuria, UTI, and hypotension and was admitted. Vitals were within normal limits. He was started on a 
broad spectrum antibiotic and started on continuous bladder irrigation via catheter. As the enrollee was 
hemodynamically stable and failed outpatient treatment for UTI with new hematuria, observation treatment 
would have been appropriate until more stable. Inpatient services were not supported in the documentation. It 
was not expected that the enrollee would have required at least a two-midnight stay in the hospital. 
 
 
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 inpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for the acute inpatient hospital care provided from February 23, 2020, to February 25, 
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoulder arthroscopy. 
 
You asked the Plan to pre-approve shoulder arthroscopy. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
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 shoulder arthroscopy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found guidelines do not support this request without detailed documentation of prior failure 
of reasonable, comprehensive conservative treatment. Exceptional findings are not evident in this scenario to 
support otherwise. Significant objective clinical and or imaging findings are not evident. Therefore, the request 
for right shoulder diagnostic arthroscopy, possible rotator cuff repair, possible biceps tenodesis, excision of 
distal clavicle, and acromioplasty is not medically reasonable or 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 shoulder arthroscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve shoulder arthroscopy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar medial branch blocks (MBBs). 
 
You asked the Plan to pre-approve these services. You say that you don't want surgery. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MBBs are covered when specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain 
that radiates down both legs. There is no documentation of physical therapy or other conservative therapies. 
You have a diagnosis of spinal stenosis and had a positive response to epidural steroid injections in the past, 
suggesting other pain generators are present. The criteria for coverage of MBBs are not met and the services 
are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar medial branch blocks (MBBs).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that your request is not medically necessary because your records 
show your vertebral compression fracture is well over 3 years old. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty is covered if the above criteria are met. 
 
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 these services. Our reviewer says that 
kyphoplasty is not medically reasonable and necessary. There is no documentation that the fracture is acute and 
less than 6 weeks old. Our physician reviewer found that your condition does not meet Medicare criteria for 
these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation (99204) to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve consultation. You say that the service is medically necessary. The Plan 
denied your request. The Plan says in-network providers are available to perform the requested service. 
 
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 consultation (99204) to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan has to pre-approve a crown (D2750) for tooth # 9. 
 
You asked the Plan to pre-approve the dental service. You say that the crown is necessary. The Plan denied 
your request. The Plan says that there is no presence of marginal decay or other significant clinical breakdown 
that would support the need for crown replacement under this plan. The Plan says that the lack of recurrent 
active decay is indicative of satisfactory crown coverage. The Plan says aesthetics is also not included as a need 
for replacement of the existing crown. 
 
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. The Plan covers the dental 
service when the services are medically necessary and reasonable. 
 
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 dental service. Our reviewer says 
that the crown for tooth # 9 is medically necessary. Our physician reviewer found the provided documentation 
indicates that the crown in place on tooth # 9 exhibits a fracture of the distal porcelain. The reviewer found that 
the fracture affects the proper function. Therefore the reviewer found that the crown for tooth # 9 is medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have been met. Therefore, we decided that the Plan has to 
pre-approve a crown (D2750) for tooth # 9.  
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care provided after 
February 1, 2021. 
 
You asked the Plan to pre-approve the SNF care. You say that SNF care is medically necessary. The Plan 
denied your request. The Plan says rules for a continuation of SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found as of February 2, 2021, the member did 
not require any skilled nursing or rehab services on a daily basis. He was not expected to make measurable 
gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with 
mobility or activities of daily living. The member did not require skilled therapy to establish a safe and 
effective maintenance program. The member received skilled care and improved; however, his function had 
plateaued and he did not require any further inpatient skilled rehab services.
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the skilled nursing facility (SNF) care provided after February 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cell harvesting for transplantation (38206) provided on 
November 5, 2019. 
 
You asked the Plan to pay for the cell harvesting. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
the service billed. 
 
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 find that CPT code 38206 is not supported in the record. Specifically, no clinical documentation has been 
submitted to support the billed service. Based on this information, we decided that Medicare rules for coverage 
of the cell harvesting have not been met. Therefore, we decided that the Plan does not have to pay for the cell 
harvesting for transplantation (38206) provided on November 5, 2019.