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

We decided that the Plan does not have to pay for the acute inpatient hospital care provided to the enrollee
from October 28, 2019 to October 31, 2019.

You asked the Plan to pay for acute inpatient hospital care. You say that this claim should be paid. The Plan
denied your request. The Plan says Medicare coverage criteria were not met. We overturned the Plans
denial due to a lack of medical records being submitted with the file. The Plan requested a reopen and provided
the required medical records.

At issue is coverage for inpatient services. New and material evidence has been submitted, and the case has
been re-opened. Our Medical Director reviewed the case file. The enrollee presented to the with an extensive
DVT in the right leg. The enrollee was in no acute distress. Treatment with IV heparin was initiated. The
enrollee was admitted to observation with a plan to call interventional radiology the following day to see if any
procedure could be done; if not, the enrollee would be switched to oral medication. No thrombolysis or
procedure was recommended; the enrollee was to be managed medically. The enrollee remained in no acute
distress. The documentation does not support that inpatient services were medically reasonable and necessary
for the enrollee in this case. 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 not been met.
Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided to the
enrollee from October 28, 2019 to October 31, 2019.

Please be advised that this provider is contracted with the Plan and should not be billing the enrollee anything
other than the contractual copayment expectation. If the provider is balance billing the enrollee, please contact
the Plan for further assistance.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.

You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria for LTACH transfer are not
met. We overturned the Plans denial. The Plan requested a reopen and stated we did not apply the
correct criteria.

Our Medical Director reviewed the case file and the reopen request. The enrollee is a 68-year-old woman with
a history of end-stage COPD, diabetes, lung cancer, and sleep apnea, who was admitted to the hospital on June
10, 2020 with a moderate right-sided pneumothorax which required surgery. The enrollee underwent VATS,
wedge resection, and mediastinal lymphadenectomy with removal of lymph nodes which were positive for
adenocarcinoma of the lung. The post-operative course was complicated by respiratory failure, requiring high
flow oxygen and BiPAP. On June 27, 2020, the enrollee had desaturation with exertion. PT and OT were
continuing. The plan is correct in this case. Long term acute care hospitals (LTACHs) are certified as acute
care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those
of short-term acute care hospitals. The enrollee was receiving acute hospital care, and acute care services were
not denied. The documentation did not support that the enrollee required services at the LTACH that were not
available at the acute care hospital where she was receiving care. The documentation did not support that
LTACH services were medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 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 for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provider has requested codes that are excluded from coverage by Medicare. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found in this case, the 
documentation doesn't support that you require skilled nursing services, a home health aide or skilled rehab 
services to provide treatment that is medically necessary. You do not require skilled nursing, a home health 
aide or rehab services to effectively provide treatment, care, and/or services in order to improve your condition, 
perform a maintenance program to maintain your condition and/or prevent deterioration. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health aide services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services (G0162) provided to the enrollee on 
December 4, 2019. 
 
You asked the Plan to pay for home health services. You say that this should be covered. The Plan denied your 
request. The Plan says this was not billed on a correct form. 
 
The Plan must follow Medicare rules. The rules say that home health agencies use one of two institutional 
claim formats to bill Original Medicare, either the 837 institutional claim or the paper Form CMS-1450, also 
known as the UB-04. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this service 
was billed on Form CMS-1500. Therefore, we decided that the Plan does not have to pay for the home health 
services (G0162) provided to the enrollee on December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided from March 1, 2020 through March 
5, 2020. 
 
You asked the Plan to pay for these services. You say that you were advised you might have to pay the 
difference between what the Health Plan pays for this service and what the out of network provider charges. 
The Plan denied your request. The Plan says that payment cannot be made to an opt out provider. 
 
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 provided from March 1, 2020 through March 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network dental provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says out-of-network services are not available. 
 
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 dental 
services when they are provided by an in-network provider. 
 
The requested dental services are to be provided by an out-of-network provider. Based on this information, we 
decided that the Plan's rules for coverage of the referral have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a referral to an out-of-network dental provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on June 8, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to you by an out-of-network provider on June 
8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the facet injection rendered on February 18, 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 procedure code 64636 is not supported. 
 
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 64636 is destruction by neurolytic agent, paravertebral 
facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint 
(List separately in addition to code for primary procedure). 
 
We find that CPT code 64636 is not supported in the medical record. Specifically, the operative report does not 
contain documentation of destruction by neurolytic agent of the paravertebral facet joint nerve(s). 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 pay for the facet injection rendered on February 18, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has the pay for the testing provided on November 30, 2019. 
 
You asked the Plan the pay for the testing. The Plan denied your request. The Plan says that this test is only 
covered once per lifetime. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The rules say that this test is expected to be provided once per lifetime, but a 
second test may be considered with supporting documentation. The Plan says that the requested test exceeds 
the frequency limitation. However, the Plan has not submitted documentation showing that the enrollee 
received this test once prior to the date of service in question. Without supporting documentation, the Plan's 
denial cannot be substantiated. Therefore, we decided that the Plan has the pay for the testing provided on 
November 30, 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 biologic materials to aid in soft and osseous tissue 
regeneration (D4265) provided on May 19, 2020. 
 
You asked the Plan to pay for the biologic materials. You say that the provider had to remove tooth #10. The 
Plan denied your request. The Plan says this service is not a covered benefit 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 pay for the 
biologic materials to aid in soft and osseous tissue regeneration (D4265) provided on May 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a GenVisc 850 injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan's preferred viscosupplements are Orthovisc and Monovisc and don't require 
prior authorization. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 injection. Our reviewer says that the 
requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee has 
tried and failed Orthovisc and Monovisc. Based on the medical records provided there is no indication that the 
plan's required drugs would likely be less effective and/or likely have adverse effects 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a GenVisc 850 injection for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit services provided on September 6, 2019. 
 
You asked the Plan to pay for the services provided. You say that the enrollee is homebound and needed 
medical services for a recent episode of hypoglycemia and syncope. The Plan denied your request. The Plan 
says the billed code does not appropriately reflect the services provided. 
 
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 99350 is not supported in the medical record. The provided records do not show that a 
physician was present in the enrollee's home at the time the services were provided. Based on this information, 
we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for the home visit services provided on September 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tooth replacement services. 
 
You asked the Plan to pre-approve tooth replacement services. The Plan denied your request. The Plan says this 
is not a covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve 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 pre-approve tooth replacement 
services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper and lower dentures. 
 
You asked the Plan to pre-approve the dentures. You say that you cannot eat because you threw out your 
dentures. The Plan denied your request. The Plan says the requested treatment exceeds the maximum count 
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 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 
complete upper and lower dentures.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (CPT 01936) provided to the enrollee on 
March 16, 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 these procedures are not separately reimbursable even when a modifier is appended. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 01936 
has a bundled relationship with code 72275 and cannot be paid as billed. This code cannot be paid as a separate 
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided 
that the Plan does not have to pay for anesthesia services (CPT 01936) provided to the enrollee on March 16, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic images obtained intraorally 
or extraorally provided on June 26, 2020. 
 
You asked the Plan to pay for these services. You say that this should be covered because you sustained an 
injury. The Plan denied your request. The Plan says that this is not covered by the 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 pay for the 2D 
oral/facial photographic images obtained intraorally or extraorally provided on June 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 10, 2020, by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the enrollee has always seen this provider, and 
does not want to change. The Plan denied your request. The Plan says the services were not referred by a 
network provider, r rendered in a participating facility. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided on August 10, 2020, by an out of network 
(OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper gastrointestinal endoscopy with biopsy 
(43235, 43239) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the upper gastrointestinal endoscopy with biopsy. You say that the services 
were medically necessary. The Plan denied your request. The Plan says the services are non-emergent. There 
are network providers available. 
 
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 services. Therefore, we decided that the Plan does not have to pre-approve the upper 
gastrointestinal endoscopy with biopsy (43235, 43239) to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Skilled Nursing Facility (SNF) stay 
provided from March 1, 2020, to March 20, 2020. 
 
You asked the Plan to waive the copayment for SNF stay. You say that you were told that if your extra time in 
the SNF was approved you would not be charged. The Plan denied your request. The Plan says the copayment 
amount you are being charged is correct. 
 
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 $0 
copayment per day for days 1 to 20 and $178 copayment per day for days 21 to 100 for in-network SNF stay. 
You previously received 18 days of SNF care in February 2020. This portion of the SNF stay lasted 19 days, 
which are days 19 to 37 of the SNF stay, which would result in a copayment amount of $3,026. You have only 
been asked to pay $2,639.15 because this amount, along with other cost-sharing amounts you have been asked 
to pay in 2020, meets the $4,950 in-network maximum out-of-pocket amount for 2020.
 
You have been asked to pay $0 copayment per day for days 1 to 20 and $178 copayment per day for days 21 to 
100 for SNF stay. SNF stay falls within the Skilled Nursing Facility (SNF) Care 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 a Skilled Nursing Facility (SNF) stay provided from March 1, 2020, 
to March 20, 2020.