Persius/hicric huggingface dataset:
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found records do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other 
medication management, wound/skin care, and daily therapy can be provided at a SNF. In this case, you are 
mostly moderate/minimal assist for functional transfers and activities of daily living (ADL?s) and a less 
intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and 
predicted period. An IRF intensity is not warranted. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided daily 
skilled services are not required. The enrollee does not require the services on an inpatient basis, in a skilled 
nursing facility setting. Services in a long-term care facility on a part time basis or in the home with home 
health services appears appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for radiotherapy planning provided on October 29, 2019. 
 
You asked the Plan to pay for the radiotherapy planning. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that Medicare does not allow late charges 
for type of bill codes 145, 745 and 755. 
 
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 Plan has failed to forward the original claim. Without this claim we are 
unable to substantiate the Plan argument that the provider originally billed with a Type of Bill code that would 
not be eligible for late charges. Therefore, we decided that the Plan has to pay for radiotherapy planning 
provided on October 29, 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 pre-approve two core buildups, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildups. The Plan denied your request. The Plan says this service 
is not covered. 
 
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, 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 two 
core buildups, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation with an endodontist.
You asked the Plan to pre-approve the consultation. You say that your dentist advised that you see an endodontist to evaluate the issues you are having. The Plan denied your request. The Plan says there is no listed benefit for dental services performed by an endodontist. The Plan also says dental services are only covered when they are received by a participating general dentist.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a consultation with an endodontist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tubal ligation surgery for sterilization. 
 
You asked the Plan to pre-approve tubal ligation. You say that the enrollee's complicating factors would put the 
enrollee at extreme risk in pregnancy. The Plan denied your request. The Plan says the denial of authorization 
for this service is correct, because Medicare does not cover tubal ligation for sterilization purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that tubal ligation is not covered for sterilization 
purposes.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of tubal ligation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
tubal ligation surgery for sterilization.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a facility polysomnography (PSG) (95810). 
 
You asked the Plan to pre-approve a facility polysomnography. You say that this is medically necessary. The 
Plan denied your request. The Plan says that a home sleep study would be more appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that HSTs may be used in addition to a face to face 
clinical assessment by the treating physician and physical examination to diagnose 
Obstructive Sleep Apnea (OSA) specifically; it is intended only for those patients who exhibit clinical signs 
and symptoms of OSA. 
 
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 facility polysomnography. Our 
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our 
physician reviewer found according to widely accepted guidelines, home PSG is best used for patients with a 
high suspicion of obstructive sleep apnea (OSA), because home PSG is less sensitive than attended PSG for 
this diagnosis.  This patient's Epworth score is 2 (normal), which lessens the likelihood of OSA.  An attended 
PSG is therefore the preferred test for this patient, and is considered reasonable and 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 a facility polysomnography have been met. Therefore, we decided that the Plan 
has to pre-approve a facility polysomnography (PSG) (95810).  
 
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 pre-approve periodontal scalings and root planings of four or more 
teeth per quadrant of the lower right and lower left quadrants and periodontal scalings and root planings of one 
to three teeth per quadrant of the upper right and upper left quadrants (D4342 x2) to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says you 
are not a contracted provider with the enrollee's plan. The Plan also says that services provided by an OON or 
non-contracted provider 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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve 
periodontal scalings and root planings of four or more teeth per quadrant of the lower right and lower left 
quadrants and periodontal scalings and root planings of one to three teeth per quadrant of the upper right and 
upper left quadrants (D4342 x2) to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical/thoracic facet injection. 
 
You asked the Plan to pre-approve cervical/thoracic facet injection. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that injections are only covered for certain indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve cervical/thoracic facet injection. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has neck pain. Treatment has consisted of medical 
therapy including opiates and physical therapy. The documentation supports radiculopathy. Therefore, the 
enrollee does not have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of 
the facet injection 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 cervical/thoracic facet injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve cervical/thoracic facet injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the charge for the outpatient hospital services provided on 
March 4, 2020. 
 
You asked the Plan to waive the charge for the outpatient services. You say that you had this same procedure 
last year and were billed for a treatment room instead of the clinic visit. You feel this was billed incorrectly and 
that the charge should be removed. The Plan denied your request. The Plan says you were seen by a provider in 
an office affiliated with a hospital. The hospital applies the facility fee for this service which was correctly 
applied to the deductible. 
 
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 $350 
copayment after the $250 deductible is met for non-surgical visits to an outpatient clinic.  
 
You have been asked to pay $140.45 for the outpatient services which is less than the applicable $250 
deductible. The outpatient services fall within the non-surgical visits to an outpatient clinic 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 charge for the outpatient hospital services provided on March 4, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polysomnography (95810). 
 
You asked the Plan to pay for polysomnography. You say that the approved code 95811 was not necessary 
during the study. The Plan denied your request. The Plan says the billed code is included in the approved code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or 
beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine 
whether payment is due and the amount of payment. 
 
We find that CPT code 95810 is not supported in the medical record. Specifically, medical records were not 
submitted for the study. Without this information, this code cannot be verified. Based on this information, we 
decided that Medicare rules for coverage of polysomnography have not been met. Therefore, we decided that 
the Plan does not have to pay for polysomnography (95810).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the below knee flexible protective outer surface 
covering system (L5962). 
 
You asked the Plan to pre-approve the below knee flex cover system. You say that the physician office notes 
and prosthetists notes were inadvertently left out of the clinicals that were attached to the request. Please see 
justification for request attached. The Plan denied your request. The Plan says this item is not medically 
necessary and not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the below knee flex cover system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the below knee flexible protective outer surface covering system (L5962).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower 
extremity (73721). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
MRI is not medically necessary at this time. Our physician reviewer found the record shows no attempt at 
physical therapy and no trial of conservative treatments such as medications or steroid injections for the 
enrollee's knee pain. MRI is not indicated until a failed trial of conservative therapy. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lower extremity (73721).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrodesis (28730) and a bunionectomy (28292) provided 
on November 11, 2019. 
 
You asked the Plan to pay for arthrodesis and a bunionectomy. You say that these codes are supported. The 
Plan denied your request. The Plan says there is not documentation showing these services were performed. 
 
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 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 arthrodesis and a bunionectomy. Our 
reviewer says that these codes are not supported. Our physician reviewer found the medical records provided 
do not include documentation of an anarthrodesis, midtarsal or tarsometatarsal, multiple or transverse being 
performed as an independent procedure on November 11, 2019, therefore code 28730 cannot be verified. The 
medical records also do not include documentation of a correction, hallux valgus (bunionectomy), with 
sesamoidectomy, when performed; with resection of proximal phalanx base, when performed, any method 
being performed on November 11, 2019, therefore 28292 cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis and a bunionectomy have not been met. Therefore, we decided that 
the Plan does not have to pay for arthrodesis (28730) and a bunionectomy (28292) provided on November 11, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection procedure (27369) provided on January 6, 2020.
You asked the Plan to pay for the injection procedure. 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 providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 27369 is injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee arthrography. We asked our coder 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 injection procedure. Our reviewer says that CPT code 27369 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to validate that an Injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee arthrography was performed on the billed date of service. 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 injection procedure have not been met. Therefore, we decided that the Plan does not have to pay for the injection procedure (27369) provided on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous moderate (conscious) sedation/ analgesia, 
first 15 minutes (D9239) & intravenous moderate (conscious) sedation/ analgesia, each additional 15 minutes 
(D9243). 
 
You asked the Plan to pre-approve the dental services. You say that the records should support the necessity of 
the services in dispute. The Plan denied your request. The Plan says this service is not covered under the plan 
benefits. 
 
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. The health plan contract says 
that any services not listed are not covered. 
 
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 
intravenous moderate (conscious) sedation/ analgesia, first 15 minutes (D9239) & intravenous moderate 
(conscious) sedation/ analgesia, each additional 15 minutes (D9243).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for an incision and removal of a foreign object (10120) provided on January 24, 2020.
You asked the Plan to pay for the incision and removal of a foreign object. You say that you would like reconsideration because this service was reported correctly. The Plan denied your request. The Plan says that the documentation only supports the surgical procedure and does not include any follow up care for the procedure performed.
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 10120 is Incision and removal of foreign body, subcutaneous tissues; simple. We asked our coder 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 incision and removal of a foreign object. Our reviewer says that CPT code 10120 meets criteria for billing and reimbursement consideration. Our reviewer found the records indicate that the provider performed a simple incision and removal of the foreign body, and felt no follow up was needed for this procedure. A modifier would be inappropriate. 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 incision and removal of a foreign object have been met. Therefore, we decided that the Plan has to pay for an incision and removal of a foreign object (10120) provided on January 24, 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.