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

We decided that the Plan does not have to pay for the lab services provided on December 10, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 requested CPT codes are not supported in the medical record. Specifically, the records 
provided do not show that lab services were performed with blood sampling. The records show that a urine 
specimen was collected. The billed services cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete maxillary and mandibular dentures. You say that you need 
new dentures because your original ones were thrown away. The Plan denied your request. The Plan says the 
services exceed the maximum counts allowed per period. 
 
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, maxillary and mandibular dentures are 
each limited to one procedure every five plan years. The record shows that you received a complete maxillary 
denture (D5110) and a complete mandibular denture (D5120) on October 18, 2018, and your denture benefits 
have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary 
denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received 
from April 25, 2020, to April 29, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you thought there 
would be no charge for this admission because you were readmitted within 30 days. The Plan denied your 
request. The Plan says you were charged this copayment correctly.  This copayment is charged per admission. 
You were admitted twice and had two separate stays in the hospital. 
 
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 $300 
copayment per day for days 1-6, and a $0 copayment per day after day 6 for inpatient hospital care.  
 
You have been asked to pay a $300 copayment per day for the inpatient hospital services. This copayment 
applies regardless of whether or not you were admitted to the hospital previously. 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 the inpatient hospital services you received from April 25, 2020, to April 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for aquatic therapy provided. 
 
You asked the Plan to pay for aquatic therapy. You say that the enrollee was pre-approved so you provided 10 
visits. You say that the claims should be processed for payment. The Plan denied your request. The Plan says 
the techniques used could have been applied using land based physical therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
 
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 aquatic therapy. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found there was no documentation in the records that land based physical 
therapy would have been inappropriate for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aquatic therapy have not been met. Therefore, we decided that the Plan does not 
have to pay for aquatic therapy provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cardiac pacemaker. 
 
You asked the Plan to pre-approve a cardiac pacemaker. You say that the requested cardiac pacemaker is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested cardiac pacemaker. 
 
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 a cardiac pacemaker. Our reviewer says 
that the enrollee does not meet criteria for the requested cardiac pacemaker. Our physician reviewer found 
based on the records the enrollee has intermittent sinus bradycardia that does not correlate with symptoms of 
dyspnea while the Holter monitor was being worn.  Likewise, there are no symptoms of syncope and no 
documented significant tachycardia that would require negative chronotropic medications forcing the need for a 
pacemaker.  Also, there is no evidence of heart block or significant pauses on the Holter monitor.  In this  
circumstance the coverage criteria for pacemaker placement are not met since there are no covered indications 
for the procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a cardiac pacemaker have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a cardiac pacemaker.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on February 11, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four labial veneers (D2960 x4), a core buildup, 
including any pins when required (D2950), and endodontic therapy (D3320). 
 
You asked the Plan to pre-approve the labial veneers, core buildup, and endodontic therapy. The Plan denied 
your request. The Plan says these services 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. Therefore, we decided that the Plan does not have to pre-approve four 
labial veneers (D2960 x4), a core buildup, including any pins when required (D2950), and endodontic therapy 
(D3320).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for pneumonia and respiratory 
failure. Medical problems are stable. There are no identified problems that need inpatient medical management. 
There are no complex nursing or rehabilitation needs. 
  
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not 
a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for aquatic therapy provided on October 23, 2019. 
 
You asked the Plan to pay for aquatic therapy. You say that the enrollee was pre-approved so 10 visits were 
provided. You say that the claims should be processed for payment. The Plan denied your request. The Plan 
says the techniques used could have been applied using land based physical therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
 
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 aquatic therapy. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found there was no documentation in the records that land based physical 
therapy would have been inappropriate for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aquatic therapy have not been met. Therefore, we decided that the Plan does not 
have to pay for aquatic therapy provided on October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 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 
physician?s services. 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 April 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) you had on 
July 8, 2020. 
 
You asked the Plan to waive the copayment for the EKG. You say that you believe this service should be 
included in your office visit. The Plan denied your request. The Plan says you were charged this copayment 
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 50 
copayment for diagnostic tests.  
 
You have been asked to pay a 50 copayment for the EKG. The EKG falls within the diagnostic tests benefit 
category. Physicians are permitted to charge separately for diagnostic tests, regardless of their necessity.  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 the electrocardiogram (EKG) you had on July 8, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99350) provided on July 8, 2019. 
 
You asked the Plan to pay for the home visit. You say that you would like reconsideration because the services 
rendered were medically necessary. The Plan denied your request. The Plan says the billed code does not 
appropriately reflect the services provided by the Certified Nursing Assistant. 
 
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 99350 is home visit for the evaluation and management 
of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval 
history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling 
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the 
presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a 
significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face 
with the patient and/or family.  
 
We find that CPT code 99350 is not supported in the record. Specifically, the record does not support that the 
physician was present in the beneficiary's home. Based on this information, we decided that Medicare rules for 
coverage of the home visit have not been met. Therefore, we decided that the Plan does not have to pay for the 
home visit (99350) provided on July 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection procedure you had at an 
outpatient hospital facility. 
 
You asked the Plan to waive the copayment for the injection procedure. You say that you don't know why this 
copayment was charged. The Plan denied your request. The Plan says you were charged this copayment 
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 $270 
copayment for outpatient surgery in an ambulatory surgical center or a hospital outpatient facility.  
 
You have been asked to pay a $270 copayment for the injection procedure. The injection procedure falls within 
the outpatient surgery 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 the injection 
procedure you had at an outpatient hospital facility.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 21, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 requested CPT codes are not supported in the medical record. Specifically, the records 
provided do not show that lab services were performed with blood sampling. The records show that a urine 
specimen was collected. The billed services cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on January 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits and occlusal device provided from June 10, 
2020, to July 7, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were diagnosed with arthralgia. You say 
that you grind your teeth at night. You say that it was recommended you use a night guard. You also say that 
your present dentist recommended you see this dentist because he felt you needed treatment that he was unable 
to give. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The 
Plan says that you must receive care from a network provider. The Plan also says that if you get services that 
are excluded from coverage, you have to pay them yourself. 
 
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. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the office visits and occlusal device provided from June 10, 2020, to July 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesacral nerve stimulation.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that sacral nerve stimulation is covered when specificcriteria 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 urinary incontinence and overactive bladder. A voiding cystometry and provocative stress tests were performed on September 28, 2020. The enrollee did not have incontinence, but when voiding she had minimal bladder activity, and needed to strain to void. There was no evidence of blockage. It was noted that the loss of bladder tone was possibly due to her diabetes. The Medicare criteria state that patients with specific neurologic diseases such as diabetes with peripheral nerve involvement which are associated with secondary manifestations of urinary urge incontinence, urgency-frequency syndrome, and urinary retention are excluded from coverage of sacral nerve stimulation. 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-approvesacral nerve stimulation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided to the enrollee on 
February 6, 2020. 
 
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 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 outpatient hospital services 
provided to the enrollee on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care services you received at a 
outpatient hospital facility on July 20, 2020. 
 
You asked the Plan to waive the copayment for the wound care services. You say that this wound care visit was 
coded differently than other visits you had. The Plan denied your request. The Plan says you were charged this 
copayment 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 $225 
copayment for medical services at an outpatient hospital facility.  
 
You have been asked to pay a $225 copayment for the wound care services. The wound care services fall 
within the medical services at an outpatient hospital facility 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 wound care services you received at a outpatient hospital facility on July 20, 2020.