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

 
We decided that the Plan has to hold you harmless for glycosylated hemoglobin testing. 
 
You asked the Plan to hold you harmless for glycosylated hemoglobin testing. You say that this should be 
covered. The Plan denied your request. The Plan says that this was not billed correctly. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided glycosylated hemoglobin testing by a contract provider. The file does not show that the 
Plan provided notice that glycosylated hemoglobin testing would not be covered. Under Medicare rules, this 
means glycosylated hemoglobin testing is considered approved by the Plan. Therefore, we decided that the Plan 
has to hold you harmless for glycosylated hemoglobin testing.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to 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 altered speech and was treated for a stroke. Medical conditions are stable. There are medical needs requiring inpatient admission. 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. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Alphagan drops. 
 
You asked the Plan to pre-approve Alphagan drops. You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Alphagan drops.  
 
Benefits for Alphagan drops may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services (99212) provided on April 3, 2018. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not emergent and there were 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physician services (99212) provided on April 
3, 2018.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology and lab reading (CPT code 78832) provided on 
April 14, 2020. 
 
You asked the Plan to pay for CPT code 78832. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services were not billed correctly. 
 
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 78832 
has a bundled relationship with code 79445 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 the radiology and lab reading (CPT code 78832) provided on April 14, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the left and right shoulders. 
 
You asked the Plan to pre-approve the MRIs. You say that you would like reconsideration based on the 
submitted clinical information. The Plan denied your request. The Plan says the member has not tried 
conservative treatments. 
 
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 MRIs. Our reviewer says that 
Medicare criteria have not been met for the requested service. Our physician reviewer found there is no 
documented trial of conservative measures for shoulder pain. 
 
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 MRIs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the left and right shoulders.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant at surgery services provided for a tracheostomy 
procedure provided on May 4, 2020 and billed with code 31600-80. 
 
You asked the Plan to pay for the surgical assistant services. You say that authorization was granted for this 
date of service and the records show that the billing provider did assist with the endoscope. It is felt this 
warrants payment for surgical assistant services. The Plan denied your request. The Plan says surgical assistant 
services cannot be paid for this service. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered.  
 
In this case, you billed assistant surgery services for CPT code 31600. The Medicare Fee Schedule Database 
contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant 
surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare 
coverage criteria for the surgical assistant services have not been met. Therefore, we decided that the Plan does 
not have to pay for the assistant at surgery services provided for a tracheostomy procedure provided on May 4, 
2020 and billed with code 31600-80.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of the Superion Interspinous stabilization 
device (22869). 
 
You asked the Plan to pre-approve this service. You say that the insertion of the interspinous stabilization 
device is medically necessary as the enrollee has lumbar spinal stenosis. The Plan denied your request. The 
Plan says the insertion of an interspinous stabilization device is not medically necessary. 
 
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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the device is experimental. More research is needed to show safety and efficacy. Additionally, there 
is no documented spinal instability. Therefore, this service is not 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of the Superion Interspinous stabilization device (22869).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a bronchoscopy provided on July 30, 2020. 
 
You asked the Plan to waive the copayment for a bronchoscopy. You say that you were not in an surgical room 
and there was an open toilet in the room. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 for outpatient surgery, including services provided at hospital outpatient facilities.  
 
You have been asked to pay a $350 copayment for a bronchoscopy. A bronchoscopy falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 bronchoscopy provided on July 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 26, 2020 by an out 
of network (OON) provider. 
 
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 the services were rendered by an out-of-network provider without 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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 26, 2020 
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided June 23, 2020 to June 29, 
2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were medically 
necessary. The Plan denied your request. The Plan says that coverage criteria was not met. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier emergency and/or observation care) would 
span two midnights. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided June 23, 2020 to June 29, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) and the 
periapical x-ray (D0220) provided on August 12, 2020. 
 
You asked the Plan to reimburse you for the oral evaluation and x-ray. You say that you fell on concrete and 
broke your tooth. You say that your lip was oozing above the area of the broken tooth. You say that your 
dentist advised that the broken piece of your tooth was embedded in your lip. You say that your lip was 
infected and abscessed. You also say that this was way more than routine dental care. The Plan denied your 
request. The Plan says the services you received are dental in nature. The Plan also says that the oral evaluation 
and x-ray are not covered services. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to reimburse you for 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 reimburse you for the 
limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on August 12, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee is appropriate for a short term care facility. 
 
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found based on the medical records provided 
there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and 
judgment of a skilled professional nurse or qualified therapist is not required to safely and effectively provide 
medically necessary and reasonable treatment. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation services (A0433 and A0425) provided on June 
9, 2020. 
 
You asked the Plan to pay for the transportation services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says a secondary only diagnosis cannot be used 
as the primary, first-listed or principal diagnosis for any procedure or service. 
 
The Plan must follow Medicare rules. Medicare rules say that the ICD-10-CM has a coding convention that 
requires the underlying condition be sequenced first, if applicable, followed by the manifestation.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the transportation services have not been met. Specifically, this claim was billed with diagnosis 
code I46.2. Per the ICD-10-CM, I46.2 has a code first note indicating that the underlying cardiac condition 
should be sequenced first. Therefore, we decided that the Plan does not have to pay for transportation services 
(A0433 and A0425) provided on June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 22, 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 physician services provided 
to the enrollee on April 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00731) provided on September 3, 2020. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration because the 
services were medically necessary. The Plan denied your request. The Plan says this claim did not include the 
appropriate primary, first-listed or principal diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that the ICD-10-CM has a coding convention that 
requires the underlying condition be sequenced first, if applicable, followed by the manifestation. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the anesthesia services have not been met. Specifically, this claim was billed with diagnosis code 
I85.10. Per the ICD-10-CM, I85.10 has a code first note meaning that the underlying condition should be 
sequenced first. Therefore, we decided that the Plan does not have to pay for anesthesia services (00731) 
provided on September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for the comprehensive evaluation (D0150), 
prophylaxis (D1110), and the complete series of x-rays (D0210) provided on July 13, 2020. 
 
You asked the Plan to pay the full amount for the dental services. You say that this was the first time that you 
saw this provider. You say that your previous dentist caused damage to your crown during a tooth extraction. 
You also say that you feel this process was necessary due to the circumstances. The Plan denied your request. 
The Plan says that 1 comprehensive evaluation is covered every 3 years. The Plan says that the frequency limit 
has been exceeded. The Plan says that the provider in this case is not a network provider. The Plan also says 
that you may be billed by the out of network provider for any amount greater than the payment made to the 
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 frequency limit of 1 comprehensive 
evaluation every 3 years has been exceeded. The record shows that the Plan paid for a comprehensive 
evaluation that you received on November 8, 2018. Additionally, the Evidence of Coverage specifically says 
that you may be billed by the out of network provider for any amount greater than the payment made by the 
Plan to the provider. Therefore, we decided that the Plan does not have to pay the full amount for the 
comprehensive evaluation (D0150), prophylaxis (D1110), and the complete series of x-rays (D0210) provided 
on July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided on April 24, 2020. 
 
You asked the Plan to pay for critical care services. You say that this is supported in the records. The Plan 
denied your request. The Plan says the time spent on this service is not documented. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent on this service 
is not documented in the submitted medical records. Without this information, this code cannot be verified. 
Based on this information, we decided that Medicare rules for coverage of critical care services have not been 
met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on 
April 24, 2020.